[House Hearing, 111 Congress]
[From the U.S. Government Publishing Office]
DEPARTMENTS OF LABOR, HEALTH AND HUMAN
SERVICES, EDUCATION, AND RELATED AGENCIES
APPROPRIATIONS FOR 2010
_______________________________________________________________________
HEARINGS
BEFORE A
SUBCOMMITTEE OF THE
COMMITTEE ON APPROPRIATIONS
HOUSE OF REPRESENTATIVES
ONE HUNDRED ELEVENTH CONGRESS
FIRST SESSION
________
SUBCOMMITTEE ON THE DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES,
EDUCATION, AND RELATED AGENCIES
DAVID R. OBEY, Wisconsin, Chairman
NITA M. LOWEY, New York TODD TIAHRT, Kansas
ROSA L. DeLAURO, Connecticut DENNIS R. REHBERG, Montana
JESSE L. JACKSON, Jr., Illinois RODNEY ALEXANDER, Louisiana
PATRICK J. KENNEDY, Rhode Island JO BONNER, Alabama
LUCILLE ROYBAL-ALLARD, California TOM COLE, Oklahoma
BARBARA LEE, California
MICHAEL HONDA, California
BETTY McCOLLUM, Minnesota
TIM RYAN, Ohio
JAMES P. MORAN, Virginia
NOTE: Under Committee Rules, Mr. Obey, as Chairman of the Full
Committee, and Mr. Lewis, as Ranking Minority Member of the Full
Committee, are authorized to sit as Members of all Subcommittees.
Cheryl Smith, Sue Quantius, Nicole Kunko,
Stephen Steigleder, and Albert Lee,
Subcommittee Staff
________
PART 5
Page
Raising Wages and Living Standards for Families and Workers...... 1
National Institutes of Health: Budget Overview/Implementation of
the ARRA/Status of National Children's Study...................... 85
Pathway to Health Reform: Implementing the National Strategy to
Reduce Healthcare-Associated Infections........................... 199
Secretary of Labor............................................... 313
U.S. Department of Health and Human Services..................... 369
U.S. Department of Education..................................... 461
________
Printed for the use of the Committee on Appropriations
DEPARTMENTS OF LABOR, HEALTH AND HUMAN
SERVICES, EDUCATION, AND RELATED AGENCIES
APPROPRIATIONS FOR 2010
_______________________________________________________________________
HEARINGS
BEFORE A
SUBCOMMITTEE OF THE
COMMITTEE ON APPROPRIATIONS
HOUSE OF REPRESENTATIVES
ONE HUNDRED ELEVENTH CONGRESS
FIRST SESSION
________
SUBCOMMITTEE ON THE DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES,
EDUCATION, AND RELATED AGENCIES
DAVID R. OBEY, Wisconsin, Chairman
NITA M. LOWEY, New York TODD TIAHRT, Kansas
ROSA L. DeLAURO, Connecticut DENNIS R. REHBERG, Montana
JESSE L. JACKSON, Jr., Illinois RODNEY ALEXANDER, Louisiana
PATRICK J. KENNEDY, Rhode Island JO BONNER, Alabama
LUCILLE ROYBAL-ALLARD, California TOM COLE, Oklahoma
BARBARA LEE, California
MICHAEL HONDA, California
BETTY McCOLLUM, Minnesota
TIM RYAN, Ohio
JAMES P. MORAN, Virginia
NOTE: Under Committee Rules, Mr. Obey, as Chairman of the Full
Committee, and Mr. Lewis, as Ranking Minority Member of the Full
Committee, are authorized to sit as Members of all Subcommittees.
Cheryl Smith, Sue Quantius, Nicole Kunko,
Stephen Steigleder, and Albert Lee,
Subcommittee Staff
________
PART 5
Page
Raising Wages and Living Standards for Families and Workers...... 1
National Institutes of Health: Budget Overview/Implementation of
the ARRA/Status of National Children's Study...................... 85
Pathway to Health Reform: Implementing the National Strategy to
Reduce Healthcare-Associated Infections........................... 199
Secretary of Labor............................................... 313
U.S. Department of Health and Human Services..................... 369
U.S. Department of Education..................................... 461
________
Printed for the use of the Committee on Appropriations
________
U.S. GOVERNMENT PRINTING OFFICE
50-763 WASHINGTON : 2009
COMMITTEE ON APPROPRIATIONS
DAVID R. OBEY, Wisconsin, Chairman
JOHN P. MURTHA, Pennsylvania JERRY LEWIS, California
NORMAN D. DICKS, Washington C. W. BILL YOUNG, Florida
ALAN B. MOLLOHAN, West Virginia HAROLD ROGERS, Kentucky
MARCY KAPTUR, Ohio FRANK R. WOLF, Virginia
PETER J. VISCLOSKY, Indiana JACK KINGSTON, Georgia
NITA M. LOWEY, New York RODNEY P. FRELINGHUYSEN, New
JOSE E. SERRANO, New York Jersey
ROSA L. DeLAURO, Connecticut TODD TIAHRT, Kansas
JAMES P. MORAN, Virginia ZACH WAMP, Tennessee
JOHN W. OLVER, Massachusetts TOM LATHAM, Iowa
ED PASTOR, Arizona ROBERT B. ADERHOLT, Alabama
DAVID E. PRICE, North Carolina JO ANN EMERSON, Missouri
CHET EDWARDS, Texas KAY GRANGER, Texas
PATRICK J. KENNEDY, Rhode Island MICHAEL K. SIMPSON, Idaho
MAURICE D. HINCHEY, New York JOHN ABNEY CULBERSON, Texas
LUCILLE ROYBAL-ALLARD, California MARK STEVEN KIRK, Illinois
SAM FARR, California ANDER CRENSHAW, Florida
JESSE L. JACKSON, Jr., Illinois DENNIS R. REHBERG, Montana
CAROLYN C. KILPATRICK, Michigan JOHN R. CARTER, Texas
ALLEN BOYD, Florida RODNEY ALEXANDER, Louisiana
CHAKA FATTAH, Pennsylvania KEN CALVERT, California
STEVEN R. ROTHMAN, New Jersey JO BONNER, Alabama
SANFORD D. BISHOP, Jr., Georgia STEVEN C. LaTOURETTE, Ohio
MARION BERRY, Arkansas TOM COLE, Oklahoma
BARBARA LEE, California
ADAM SCHIFF, California
MICHAEL HONDA, California
BETTY McCOLLUM, Minnesota
STEVE ISRAEL, New York
TIM RYAN, Ohio
C.A. ``DUTCH'' RUPPERSBERGER, Maryland
BEN CHANDLER, Kentucky
DEBBIE WASSERMAN SCHULTZ, Florida
CIRO RODRIGUEZ, Texas
LINCOLN DAVIS, Tennessee
JOHN T. SALAZAR, Colorado
Beverly Pheto, Clerk and Staff Director
(ii)
DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES, EDUCATION, AND RELATED
AGENCIES APPROPRIATIONS FOR 2010
----------
Wednesday, March 25, 2009.
RAISING WAGES AND LIVING STANDARDS FOR FAMILIES AND WORKERS
Mr. Obey. Well, good morning, everyone.
Before we start, I was telling Professor Krugman I know he
came in harried and worried he was going to be late. I recall,
when I was in college, one of my best friends was a person by
the name of Bill Steiger, who later came to Congress two years
before I did. Unfortunately, he was on the wrong side of the
political aisle but we remained very good friends. But we were
both in a constitutional law class together and I remember the
second day of class our professor was David Feldman, who was
tough. He was like the old character you saw in The Paper
Chase, the old TV series a long while ago.
And Feldman had begun his lecture when Bill Steiger walked
in, about two minutes late to the class, and Feldman pulled his
glasses down on the end of his nose, looked over at Steiger and
said, Mr. Steiger, he said, let me apologize. He said,
ordinarily we would have an usher escort you to your seat.
Unfortunately, our carnations have not yet arrived.
So I got a kick out of it to think that it was the
professor who was two minutes late, rather than the student.
But I know how tough it is to get down here. I appreciate your
coming and I appreciate all the panelists being with us here
today.
Let me simply make a few remarks, Mr. Tiahrt can make a
couple remarks, and then turn to our first witness.
This Subcommittee has a huge amount of work to do and it is
really, I think, the workhorse of our domestic discretionary
portion of the budget, certainly in terms of the work that we
do in trying to deliver help and services to millions of
American families all across the Country. And we have had an
especially rocky time trying to deal with, first of all, the
economic stimulus package and then the omnibus appropriations
bill. And now, shortly, we will have a budget from the new
President and we will have to act on that in short order.
But I thought that it would be important to place
everything we have been doing, as well as everything the
President will be doing in his new budget, in the proper
context, and here is what I mean.
Both parties seem to have a narrative about what has
happened in the economy. The Republican party seems, by and
large, to say, well, this was all caused, or largely caused, by
what happened in the housing market and it is the collapse of
housing that has led to this problem. And I think the
Democratic narrative seems to be, well, if those guys on Wall
Street had just behaved like adults, we would not be in this
mess.
I frankly think that both narratives are oversimplified. I
will agree that those two events were the triggering events
that caused a lot of problems in the economy, but I think there
is an underlying problem that I would like to see addressed
today, and that problem is simply this: From World War II until
about 1973, this economy grew in a fairly healthy fashion, and
that increased prosperity was shared roughly across the board,
regardless of income group.
That started to change around the middle 1970s, and from
1980 on we saw a much larger share of income growth go into the
pockets of the most well-off 10 percent; and certainly, in this
decade, we have seen an even larger share of income growth in
the economy go into the pockets of the top 10 percent.
And that has meant that the other 90 percent have really
been struggling to stay even, they have been struggling for
table scraps. And I think they tried to maintain their living
standard or expand their living standard by borrowing, so they
borrowed for lots of things--for education, to pay for health
care, to pay for consumer goods, to pay for cars, you name it.
And that house of cards sort of came crashing down when the
housing and banking and credit crises hit.
So now we have the question not only of how we get out of
this recession, but also how we build the kind of economy in
which all families can share in what we hope will be the
renewed growth in prosperity down the line once this recession
is over.
So we are going to have two panels today to talk about that
problem, and especially with our first panel this morning we
will have a focus on the inequality that has developed in this
society and what might be done to deal with that inequality as
we try to dig ourselves out of this recession; and our first
witness, Dr. Krugman, will address himself to that.
But before he does, I would like to call on Mr. Tiahrt for
whatever comments he would like to make.
Mr. Tiahrt. Thank you, Mr. Chairman. I would like to also
welcome the witnesses for both panels and welcome Dr. Krugman.
Mr. Chairman, I want to thank you for putting today's
hearing together. I think our discussion today will really get
to the heart of the philosophical differences in America when
it comes to the issues surrounding our economy. There is no
question in my mind that everyone in this room wants to return
to our Country's historic economic success. I think there is
considerable disagreement on how we get there. But I think at
least we can start with the statement that we all want to end
up in the same place, a place where our children can start a
business or find a high quality and high-paying job.
Today's discussion--indeed, the focus of the entire
Congress--should be on how we renew the dream, the American
dream. I do not subscribe to Keynesian economics. Every thin
dime Congress spends or, more appropriately, borrows is the
functional equivalent of a thick quarter that our children in
Kansas and across the rest of America will have to pay back
later.
And I have yet to see a Government job that pays for
itself. I do not believe that massive deficit spending on
things like comparative effectiveness research, which I believe
will read to rationed health care, or propping up local and
State governments, as done by the stimulus bill recently, is
going to create the private sector jobs in the short term or
revive our economy.
All we seem to be creating is more bureaucracy. And, as I
said, I have yet to see a government job that pays for itself.
My view is that one of the worst things that we can do as
Congress is to follow macro economic policies that result in
raising taxes on American citizens and employers. We have
enjoyed economic success in the past in large part because of
our relatively low tax rates. To raise taxes will, in my view,
not only hurt the American wallets immediately, but also stifle
the prospect of economic prosperity in America in the near
future. Sadly, this is where the Administration is headed.
What is even more concerning to me is the discussion of a
second stimulus bill. Frankly, I do not think the first one has
been around long enough to determine it has had any impact. My
view is that the first stimulus bill will not work, not because
it is not big enough, but because it is misguided in its
economics. To pass a second stimulus bill that makes the same
mistakes as the first seems unwise to me.
The President has made a great deal recently about
Republicans being the party of no. Simply not true. We have
great ideas that simply have been shut out of the process.
And, by the way, Chairman, I want to thank you for not
shutting us out of this process today.
I am ready to say yes; to say yes to policies that will
help rebuild a sound economy for today and the future. We need
to pursue common sense microeconomic policies that work and
reduce the uncontrollable costs that people are facing, those
who keep and create jobs here in America. And I think it starts
by reducing the size and scope of the government that has
strangled growth.
We need to move towards a competitive business tax whose
rates will compete with the rest of the world. Ireland, though
it has been caught up in a worldwide downturn, is well poised
to recover as it welcome companies and fosters growth.
We need desperately to pursue common sense approaches to
regulation, with a cost-base justification of the rules our
bureaucrats impose on those who keep and create jobs.
We need to be energy independent. I think it is well passed
the time that we adopt a loser-pays approach to litigation, as
the United Kingdom follows.
And, finally, I hope we discuss the rising cost of health
care, in addition to ensuring health care access, which is one
of the biggest burdens on our economy. I believe a consumer-
based approach to health care delivery can benefit patients and
the economy.
These ideas build the fundamental strength of our economy,
and that is how we can renew the dream and renew the
opportunity for ourselves and our children.
I would just like to close by saying although we are
struggling today, I am confident and optimistic that the
American people will overcome this downturn, as they always
have. My concern is that borrowing and spending will prolong
the pain, instead of fixing the problem.
I look forward to the discussion today and yield back.
Mr. Obey. Thank you.
----------
Wednesday, March 25, 2009.
RAISING WAGES AND LIVING STANDARDS FOR FAMILIES AND WORKERS
WITNESS
PAUL KRUGMAN, PH.D., NOBEL LAUREATE IN ECONOMICS
Mr. Obey. Let me simply welcome our first witness, Dr. Paul
Krugman. As I mentioned earlier, Mr. Krugman is a distinguished
Nobel Prize winner and Professor of Economics at Princeton
University. He is also a Centenary Professor at the London
School of Economics and an op-ed columnist for The New York
Times, and one of the 50 most influential economists in the
world today. His professional reputation rests significantly on
his work in international trade and finance. He is the author
or editor of 20 books and more than 200 papers. He is also well
known for his work on income distribution and public policy,
which is the subject of his remarks, largely, this morning.
I want to mention that we have agreed to let Dr. Krugman go
at 11:30 so he can make a prior commitment at the Swedish
Embassy.
I appreciate your being here, Dr. Krugman. Please proceed
with your statement.
Mr. Krugman. Thank you, Mr. Chairman. And thank you, Mr.
Tiahrt.
Well, as everyone is aware, this hearing is taking place at
a time of economic crisis. Unemployment is rising steeply and
the outlook for working Americans is the grimmest it has been
since The Great Depression. Two years ago, few, including
myself, imagined that things could get this bad.
We all hope that the President's policies can pull the
economy out of its tailspin. But even if he does succeed in
that goal, that will not be enough. The U.S. economy was
failing to serve the needs of the American people even during
the good years of the current business cycle.
I find it instructive and depressing to consider the state
of the economy for ordinary Americans in 2007, which was as
good as it got in recent years. By almost any measure, the
economy was worse for a majority of families in 2007 than it
had been in 2000, and there was, if you believe the numbers,
which I mostly do, surprisingly little progress even over a
much longer period, reaching back three decades.
So median family income, adjusted for inflation, was
actually slightly lower in 2007 than it had been in 2000. And
if we got back several decades, to 1979, we find that median
income rose only 15 percent over a period of almost 30 years,
less than half a percent annually. Virtually all of that rise,
by the way--this is not a partisan point, but just an
observation--took place during the Clinton years. That compares
with sustained income growth at more than 2 percent a year
during the great post-war boom, post-war generation.
The poverty rate in 2007, which was an alleged boom year,
was 12.5 percent, not only higher than the 11.3 percent rate in
2000, but higher than the 11.7 percent rate in 1979. If one
believes the numbers, none of America's economic growth over
the past generation has trickled down to America's poor.
And the health insurance situation worsened substantially.
The percentage of the American population without insurance
rose sharply in the late 1980s and the early 1990s, sparking an
unfortunately failed attempt at health reform. The situation
then improved somewhat for a while, thanks to cost control and
a booming economy. But since 2000 health care costs have once
again risen much faster than wages, leading to a growing
problem of uninsured Americans even when the economy is
growing. It is almost certain that the current crisis will soon
present us with a major crisis of lost health care coverage.
So why has a growing economy failed to deliver for ordinary
Americans? One major reason is growing income inequality. Many
of the gains in income went to a small minority of very well-
off people, with most workers seeing little rise in real wages.
Even using Census data, which missed the growth in the highest
incomes, average household income rose twice as fast as median
household income; that is, income growth over the past 30 years
would have been twice as fast if it had not been for growing
inequality.
There is also a secondary reason for the failure of
economic growth to help many Americans, which is our
dysfunctional health care system. We are unique among advanced
countries in not having some form of universal coverage, yet we
spend far more to cover 85 percent of our population than our
counterparts spend to cover everyone, with no evidence that we
receive correspondingly better care.
For both these reasons, there has been a remarkable
disconnect between the state of the economy, as measured by the
growth of GDP, and the experience of most Americans. And if
that disconnect continues, recovering from the current
recession, urgent though it is, will still leave major economic
problems unsolved.
So what can we do to end the disconnect? Reducing income
inequality is a difficult task. The truth is that while we have
some ideas about what might work, there is little reason to be
confident about the efficacy of whatever measures we try. The
Great Compression of the New Deal, which created the middle
class society of the post-war era, the society I grew up in, is
an inspiring role model, but, in honesty, I cannot promise that
we know how to repeat that experience.
Health care reform, on the other hand, is something we know
can work. Study after study has demonstrated that the U.S.
health care system is not just harsh and unfair, it is highly
inefficient. We have extremely high administrative costs,
largely because insurers work so hard not to cover the people
who need insurance most. We lag in the use of information
technology. We have a combination of inadequate care for many
Americans and vast spending on dubiously effective care for
many other Americans.
I might also note that our health care system under-invests
in preventive measures that could save money, as well as lives.
A reasonable estimate is that successful health reform
could eventually save several percent of GDP while
substantially improving the lives of most Americans. As anyone
who has studied proposals to promote economic growth knows,
that is huge. Even a drastic increase in private investment,
achieved by whatever means, would be highly unlikely to yield
that big a result.
Can we afford health care reform in the face of projected
large fiscal deficits? To borrow a phrase, yes, we can. In
fact, we must. First of all, there is no reason to be concerned
about the level of deficits, per se, the dollar figure per
year, in the near term, by which I mean the period likely to
extend for three or four years before the economy recovers.
In normal times there is reason to worry that deficits will
crowd out private investment and raise interest rates. In the
current situation, however, the world economy is, in effect,
suffering from an excess of desired saving. Even at a zero
interest rate, businesses are not willing or able to invest all
the savings the private sector wants to undertake. As a result,
government deficits actually stimulate economic activity in the
current situation by giving those savings a place to go. Those
deficits do not crowd out private investment. In fact, they may
well crowd it in.
We do need to worry about Government debt. There are real
concerns about the sustainability of very high levels of debt
in the future. However, we need to realize, even though this
sounds striking, maybe a little crazy, that a trillion dollars,
more or less, of debt over the next decade is virtually
irrelevant to America's long-term fiscal position. That
position is, instead, dominated by the rising projected costs
of our entitlement programs, mainly Medicare and Medicaid.
And the only way to reign in Medicare and Medicaid costs is
through a thorough reform of our health care system. To put off
health care reform out of fear of deficits would be a monstrous
case of being penny wise and pound foolish, sacrificing the
Nation's long-run fiscal prospects for the sake of holding
current numbers below some artificial threshold.
In dealing with the deficit, and also in dealing with
health care, we need to take the long view, and that long view
says that we should proceed with massive reform now.
Thank you.
[The information follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Obey. Thank you very much, Dr. Krugman. Let me ask a
couple questions. As you know, we have passed a significant
budget stimulus package, and there are those who feel that that
is a significant mistake because it adds to the deficit. You
have indicated in your testimony that what we ought to be
focused on is not the near-term, year-by-year deficit, but the
long term level of deficit; and that, in fact, in the short
term, deficits may be essential in order to prevent worsening
of the economic situation.
We now have the Budget Committee about to mark up budget
resolutions for the year. The Budget Committee process is
fairly interesting; it is the only process I know where you can
cut budgets without cutting programs, because they do not have
to tie macroeconomic decisions to micro results. And there are
those who will say that, now that we have passed an economic
stimulus package, about a month ago, we need to scale back on
the size of expenditures and scale back on deficits next year
and the following year.
Tell me why you think that that would not be a good idea at
this time.
Mr. Krugman. We first need to measure the stimulus package
against the current needs of the economy. President Obama
estimates that his package will, at its peak, add about 3.5
million jobs to what we would otherwise have had, and that
estimate is consistent with most economists' ballpark models.
That is helpful, but the U.S. economy has already lost almost
4.5 million jobs in this recession, and that is against the
backdrop of a growing population. So we are almost 6 million
jobs short of where we should be already, and losing jobs at
the rate of 600,000 a month.
So the package as it now stands is mitigating, it is not
even enough to prevent us from having a very severe recession;
it is just a mitigating factor.
If we respond to concern about the size of the package by
scaling back other government spending, we are undoing the
effects of the stimulus package, making it even more
inadequate. And it is really important to bear in mind, to have
some sense of what the long-run magnitudes are here.
The stimulus package is approximately $800,000,000,000.
That is the headline number. Because it will stimulate the
economy, some of that comes back in the form of higher tax
revenues. A reasonable guess at the true cost is on the order
of $500,000,000,000, which is 3 percent of GDP. That is
significant, but it is certainly not make or break if we are
thinking about the long-run budget prospects of the United
States; and we certainly should not be sacrificing crucial
priorities in the interest of offsetting the cost of this very
necessary temporary measure.
Mr. Obey. Another question, on the issue of inequality. Why
should we be concerned with growing inequality in the economy?
I mean, it may offend our sense of fairness and justice, but in
terms of the long-term strength of the economy, why should we
be concerned if we have growing inequality?
Mr. Krugman. Okay, there are two levels of answer to that.
The first is that rising inequality means that the majority of
the population gets less than an equal share of economic
growth. And I actually addressed that briefly in the opening
remarks. If we had not had rising inequality these past three
decades and had had the same rate of economic growth, the
standard of living of the typical family, the median family,
would have grown at least twice as fast as it did. The pie may
be growing, but if an ever-growing share of that pie is going
to a small group of people, most people end up not seeing their
incomes rise as fast as the average.
Beyond that, we have more speculative, but probably real,
aspects in which a highly unequal society ends up being a
dysfunctional society. There are somewhat abstract, but very
real, issues of trust, sense of community, and there are much
more real, I think, economic concerns. If we ask ourselves how
did we get into this financial crisis, an important aspect of
it was that players in the financial market were prepared to
take huge risks with other people's money because, at least for
a while, they could earn extraordinary incomes.
People who defend high inequality says that it creates
incentives, which it does, but I think what we have just
learned is that those incentives are not necessarily incentives
to do good things; they can sometimes be incentives to do
extremely socially destructive things.
If I just say look at the historical record, the most equal
income distribution the United States has ever had was during
the generation following World War II. That was when we truly
were a middle class society, when we were certainly not an
egalitarian society. We were not Cuba, but we were a relatively
equal society. That was also the era of the greatest economic
growth that we have ever achieved, before or since.
So I do not want to push those things too far. I think the
most important, the clearest argument is if you have rising
inequality, then most people do not share fully in economic
growth. But there are reasonably good reasons, looking at the
historical record, to think that a highly unequal economy is a
worse economy and a worse society.
Mr. Obey. One last question before I pass the witness.
There has been some considerable debate in this Country about
the relevance of what Roosevelt did in 1932 to the existing
situation. As I read history, what happened is that when
Roosevelt came in to power, we had unemployment approaching 25
percent, and that Roosevelt took actions to build confidence
and provide some modest stimulus, which brought down the
unemployment levels to a modest degree. But then, after 1936,
he seemed to feel that the economy was recovering and on the
road back, and he throttled back and tried to turn more toward
a balanced budget and, as a result, the economy again dipped
and it took until World War II to really achieve full
employment.
The lesson I would draw from that is that it would be a
mistake for us to throttle back too soon on stimulating the
economy. What is your reaction to that interpretation of those
events?
Mr. Krugman. Very much in agreement. What happened in 1937
was a broad resurgence of the old orthodoxy, both about
balanced budgets, even in a time of high unemployment, and
monetary policy. So there was a shift towards a more
contractionary monetary policy as well. And the economy slid
back down in what was, at the time, often referred to as the
Second Depression and did a great deal to undermine the
economy, as well as the New Deal agenda.
We can also look at the Japanese experience in the 1990s,
which offers a quite similar story. If we look at the Japanese
behavior circa 1996, same thing. It is often said that the
Japanese policy of public works to support the economy did not
work. Actually, it did when it was pursued; it did expand the
economy. But they too had a sudden burst of premature
orthodoxy, leading to the Japanese economy slipping back again.
So there is a real concern. And one of the great concerns,
I may say, about the stimulus bill as written is that it will
deliver its peak support to the economy next year and then fade
out quite quickly, and there is no solid reason to believe that
stimulus will cease to be necessary in 2011. The CBO's
projections show the economy recovering, but that is not a
result, it is an assumption. They basically simply imposed the
idea that we will return to normalcy five years from now, and
it is very hard to see what the forces leading to that return
are. So I am very concerned that it will, in fact, be deja vu
all over again, that just as the Japanese repeated Roosevelt's
experience, that we will then repeat the Japanese experience.
Mr. Obey. Thank you very much.
Mr. Tiahrt.
Mr. Tiahrt. Thank you, Mr. Chairman.
First, I would like to talk about your statement on rising
inequality. I think, in looking at those broad categories, we
fail to see what has happened during that time with people who
were previously in those categories. There has been a mobility
of out-of-the-bottom, the lowest quintile, or people we would
consider poor, into the middle class. About 54 percent moved
out of the bottom quartile into either the next quartile or the
middle quartile. I am sorry, quintile, five categories instead
of four.
So when you just look at the number--because we do have new
people coming into the economy, people coming in to work now
that did not work before; and that happened during the time
period that you are referring. So if you look at the upward
mobility, there has been a high rate of people moving out of
that bottom quintile into other categories during the same
period of time.
And you mentioned the 1950s. It is an interesting study of
economics from the Depression up until today, because I think
we remained stagnant. There were some ups and downs, but our
economy was relatively stagnant during the 1930s, where we
borrowed a lot and spent a lot. I think it was the
capitalization that occurred during World War II and the
opportunity when these people came back from World War II,
young men and women with a can-do attitude that took this
capital investment that occurred during World War II and came
up with new ideas and new innovation, and that is how we saw
this expansion of the middle class.
So my concern today, as we move forward, is that we focus
on this macro level and we say--and I believe that 98 percent
of the people in Congress today are macroeconomics Keynesians.
I believe there are very few that look at the microeconomics
that build the aggregates that you study in macroeconomics. In
order to build that microeconomic concept, we have to go down
and look at small businesses, the people who keep and create
jobs. In Kansas today, four out of five jobs are small business
jobs.
So developing a structure where they can have opportunity
is what I am concerned about. I think that is what builds a
strong economy from the bottom up, and not from government
down.
And I look at policies. You mentioned that this massive
spending may have some failure in the future. We will have a
spur or a bump in 2010 that could go away in 2011, if I
understood your testimony right. If I look at what we are doing
today, this year the Federal Government is going to go out and
borrow $3,000,000,000,000. And apparently we are not doing too
well because last week the Fed printed $1,000,000,000,000 in
new money. So we are putting more money into the economy by
creating, by printing it. What impact does that have on
inflation when you print money and have more money available in
an economy?
Mr. Krugman. Okay, that is a long list of questions. Let me
do the best I can.
Just, first, about income mobility. Yes, we are not a caste
society. People do move up and down. However, the extent of
those moves is often greatly exaggerated. Yes, there is a
changing mix of people, but the last study I have seen says
that, even after a decade, if we are looking at the top 1
percent or so of the population, after a decade, most of the
top 1 percent is the same people who were still in the top 1
percent a decade earlier. We are not actually looking at a
situation where it is a constantly changing cast of characters.
And perhaps most important for comparisons across time,
income mobility has, if anything, probably declined in the
United States. So to the extent that we have always been a
Country in which people move up and down, which somewhat
reduces the sort of lifetime inequality of income, that is no
more true and, if anything, less true now, than it was 40 years
ago.
Mr. Tiahrt. I think if you look at the lifestyle of people
in these five quintiles, people have a better lifestyle today
than they had in the 1950s.
Mr. Krugman. I think that there is a substantial illusion
in that. I mean, certainly people are better off than they were
in the 1950s, and in some respects there are things that we----
Mr. Tiahrt. Well, let me ask you this. And I have been to
the poorest area in Kansas. People there live in single-family
units; they have refrigerators, they have telephones, they have
cable TV, they have microwaves, they have cell phones. How much
of that existed in the middle class in the 1950s?
Mr. Krugman. Obviously, not microwaves and cell phones,
which had not been invented yet. But this is always--I think
your relevant comparison would be how secure did people feel in
a middle class lifestyle in, let us say, not 1950, let us say
1970 versus now. I think people are much less secure in that
style.
And, yes, some things are much better. Other things are
worse. People were more sure that their local public school
would give their children a decent education in 1970 than they
are today. People were more sure that their company retirement
fund would continue to cover them, that they actually had a
secure retirement. People were less terrified that they would
lose health insurance and be bankrupted by medical costs.
Mr. Tiahrt. I would agree with you, and I think it is
macroeconomics and the Keynesian policies that got us in this
position. And what will get us out, in my belief,--and I would
like your view on this--is if we create jobs, private sector
jobs--and how you do that is the question--if we create jobs
that will generate revenue for the government and will create
investment.
I disagree with you on savings. I think savings is a good
thing, not a bad thing. And if you look at the spending we have
been doing here on the Federal level, spending is not the
answer. But if we create opportunity so we can create jobs, by
doing that I think you remove the uncontrollable costs that
employers are facing today. Those costs are all driven by the
government, but reduce or remove those costs. Having more jobs
in America is one of the things we are looking for, is it not?
And how do we get to that?
Mr. Krugman. Two things. First, nothing in the experience
of the last two decades supports at all the view that changing
taxes in the range that is under discussion is going to be a
bad thing for job creation. We have as close to a controlled
experiment as you will ever get in economics. We had one
President who came in, raised taxes, raised the top marginal
rate, was followed by an extraordinary explosion of job
creation, and then the next President cut the top marginal rate
and even before the recession took place, job creation was
quite anemic.
You can say there were other factors, but there is
certainly nothing in that record to support a hardline view
that any increase in taxes is going to be destructive of jobs
and that cutting taxes is always the way to create them. It
just did not work that way in the past 20 years.
And the view that as long as the microeconomics, the
private sector is all good, then nothing bad can happen to the
economy is completely belied by economic history. The U.S.
economy of the 1920s was a marvel, it was more creative,
arguably, than it has ever been. It was full of driving
innovation, full of remarkable new businesses, new business
ideas; and then something terrible happened. And I guess my
basic view is, by all means, entrepreneurship, innovation,
productivity are wonderful things, but one Great Depression can
ruin your whole day.
Mr. Tiahrt. Thank you for being very generous with your
time, our Committee's time, Mr. Chairman.
I just think if you look at, for example, the 1990s, a tax
increase was followed by limiting the growth of government
during the 1990s. We limited the growth of government and that,
coupled with revenues, as you say, increased, was what allowed
us to balance the budget for four consecutive years. And my
concern is if we do not control the growth of government, no
matter what we do there is going to be a problem.
Thank you, Mr. Chairman.
Mr. Obey. Mrs. Lowey.
Mrs. Lowey. Thank you very much.
As an admirer and reader of your column, many of us look at
it as the truth. So we are very happy that you are out there.
For many of us, discussing wages and standard of living
without acknowledging the impact that the economic crisis is
having on families across the Country certainly is not
adequate, and one of the most troubling aspects that I see is
that almost every check in place to present this kind of
disaster failed.
For example, if a lender approved a loan likely to fail, an
underwriter responsible for verifying the income on the
application should have flagged the loan. When that did not
happen, an investment firm on Wall Street began buying bad
mortgages and bundling them into securities. Executives there
should have investigated the mortgages' level of risk, which
they did not because they were all making so much money. And
even if both the lenders and investment banks were not
effective in weeding out bad loans, rating agencies charged
with analyzing the risk of mortgage-backed securities should
have been raising red flags.
Yet, in case after case, each of these levels, from the
lender to the underwriter to the investment firms to the rating
agencies, there was monumental failure.
Now, many of us recognize that there is not a silver bullet
solution to solving the crisis, and it will take a combination
of approaches, and I appreciate your mentioning health care.
And, as we know, this is a prime focus of this Administration,
this President.
And I read your column the day after, or it was probably
the day of Geithner's presentation of his plan and the market
soared. Now, there are many out there who will say, well, the
market is soaring, Geithner is right, Summers is right, Krugman
is wrong. I wonder from you what can be done to change both the
industry and the culture that led to the poor decisions and
investments that harmed our economy, and how do we prevent this
happening again.
I will speak to many of my constituents--my district is
very varied, but many will say, oh, it is just a cycle, you
know, it goes up and it goes down, and do not worry about it.
And then they see the market going up and there can be a great
big move, and, okay, things are working again, forgetting the
greed and the 40:1 leverage, etc., etc., etc.
So how do we make these changes? Are you confident that we
can do it, given the fact that health care will remain key on
the agenda?
Mr. Krugman. Okay, Mrs. Lowey. About the market reaction--
--
Mrs. Lowey. They would read your column.
Mr. Krugman. My old teacher, Paul Samuelson, famously said
that the market had predicted 9 of the last 5 recessions. More
contemporaneously, though still showing my age a bit, I would
say that the market thought that pets.com was a great idea. So
I do not want to place too much weight, certainly, on what
happens on a day or even a year in the market.
There is a fundamental, philosophical, you might say,
debate, which you will probably read a bit more about in my
next column, about whether the system of finance that we
developed, not just these past couple of years, but over the
past quarter century or more, was fundamentally a good idea or
a deeply, deeply flawed system. And I believe that the
Administration still thinks it was mostly a good thing. I think
that is a point of difference between them and myself.
We went from the old modeling, in which there were banks
and banks made loans and they held on to those loans, to a
model of highly securities finance, where a loan originator
would make a loan and then sell off the loan, which would then
be sliced and diced and turned into more complex financial
instruments.
And what we know for sure is that the incentives in our
financial system were deeply, deeply flawed. Essentially, if
you were a manager in that system, you made a great deal of
money by creating the appearance of profit. And even if the
whole thing blew up after five years, you would walk away with
a large sum of money. And at some level, ultimately getting the
compensation schemes right is critical.
I think we can also ask ourselves--and I will just try to
end this--do we have too much finance in this Country. I have
been working on this a bit and noticing that during the 1960s
the finance sector was about 4 percent of GDP. In recent years
it has been 8 percent of GDP. Is that extra 4 percent of GDP
creating value or is it, as I am now starting to think,
actually destroying it?
Mr. Obey. We are going to have to hold people to five
minutes or some members will not get a chance to question Dr.
Krugman before he leaves at 11:30. So I am sorry to say the
gentlewoman's time has expired.
Mrs. Lowey. I have to go back to my hearing. Hopefully, we
will have another session at Rosa DeLauro's house, where we
enjoyed you.
Mr. Krugman. Yes.
Mrs. Lowey. And Elizabeth Warren came the other night, and
she agrees with you.
Mr. Krugman. I am sure Betsy does, yes.
Mrs. Lowey. Thank you.
Mr. Obey. Mr. Alexander.
Mr. Alexander. Thank you, Mr. Chairman.
Doctor, on the second page of your testimony you said,
talking about the dysfunctional health care system: ``We spend
more to cover 85 percent of our population than our
counterparts spend to cover everyone, with no evidence that we
receive correspondingly better care.'' Could one assume, after
reading that, that you are implying that if we cover everyone,
we would both get it cheaper and better?
Mr. Krugman. Yes. Just take the issue of administrative
costs. Medicare, which, although we do not think of it this way
often, is a single payer system covering Americans 65 and
older, spends about 3 percent of its budget on administration.
Private health insurance companies spend approximately 14, even
though most of their practice is group coverage through
corporations, which should be relatively cheap.
The best available estimates suggest that the U.S. system
spends about 30 percent of its total on administration;
whereas, other countries' systems spend on the order of half
that.
Why are administrative costs so high? Essentially because
of the cost of underwriting, insurance companies attempting to
figure out who not to cover, and because of attempting to shift
the cost onto someone else. It is very high costs imposed by
the non-universality of coverage. And if you try and look at
who the uninsured are and what it would cost, just on the
administrative cost savings alone, it ought to be cheaper in
total to cover everybody than to do what we now do.
Mr. Alexander. Okay. I also find it puzzling you said that,
comparing the amount of money, cash, that is in the system
today, we are 8 percent versus 4 percent at some time in the
past. If that is the case, then why do we have those excited
about the idea that the Treasury might inject yet another
$1,000,000,000,000 into the system, if you are implying that we
already have too much cash might be the problem?
Mr. Krugman. As you may have gathered, I was not fond of
the plan announced by the Treasury this week, and there is a
great difference between the measures that the Federal Reserve
has been undertaking, which are an attempt to promote new
lending, and the Treasury plan, which is simply an attempt to
pour money into the existing banks without necessarily coming
out and lending on the other side.
We do have a problem that financial institutions, some of
the key ones, are crippled by inadequate capital, and we need
to find a means of recapitalizing them. But that is not the
same thing as saying that we want the sector to expand. And,
no, I think we do need to face up. We will eventually have to
face up to the notion that there is not going to be as much of
a finance sector as we had in 2006, and that it will be a good
thing when it becomes a smaller part of our economy than it has
been in recent years.
Mr. Alexander. And if it appeared that I was implying you
were excited about it, I apologize. I did not intend to.
Thank you, Mr. Chairman.
Mr. Krugman. May I say, if you were an owner of bank stock,
the notion that the Treasury is about to throw
$1,000,000,000,000 in your general direction would probably be
regarded as a good thing, regardless of whether it works or
not.
Mr. Alexander. We have sensed there is some excitement out
there.
Mr. Krugman. Yes.
Mr. Alexander. Thank you.
Mr. Obey. Ms. DeLauro.
Ms. DeLauro. Thank you very much, Mr. Chairman.
Thank you, Dr. Krugman. It is a pleasure to have you here
this morning. I am going to pass on the temptation to talk
about the financial situation, but let me move, because I think
this whole issue, one that has been a real concern to me over
the years, is the whole issue of income disparity.
You say in your testimony that when reducing income
inequality ``there is little reason to be confident about the
efficacy of whatever measures we try.'' Let me ask why such
pessimism. If you were at the helm of a policy-making
institution like this institution, what are some of the ideas
that you would develop and implement to try to turn this
around?
You point to health care, and I understand that. That is
something that we need to do and something that we can work at.
What else? Where else would you prioritize in terms of this
issue?
Mr. Krugman. I am sorry you asked that question. Let me
say, quickly, two things. The great leveling of the American
income distribution, the Great Compression which took place
under FDR, took place under extraordinary circumstances. First,
there was a tripling of the size of the union movement thanks
to the combination of the Depression and a change in the
political environment; and, secondly, there was World War II,
which was a great equalizing factor. And the important lesson
from that was that those changes stuck for 30 years. It turned
out that having altered, in effect, the bargaining position of
American workers, we got a more equal distribution, which
lasted a long time, without any adverse economic effects. So
that is the great inspiring lesson.
But since we are not planning to have a second Great
Depression and a third World War, I hope, it is going to be
difficult to carry out measures on anything like that scale.
What we can do are, I think, on two fronts. Some of the
increased inequality reflects increasing disparities based on
educational level training skill. So it is almost certainly a
good thing to invest in better education, especially not at the
highest end, but for the population at large training. But my
read says that that is probably going to have only a modest
impact on inequality, even if we do a lot of it.
The second thing we can do is try to enhance the bargaining
power of workers. And I am very much a supporter of the
Employee Free Choice Act, which is the cutting edge of that
discussion right now. There is no fundamental reason in people
who say that a stronger labor movement does not make sense in
the 21st century I think are missing the realities. They are
thinking that modern labor negotiations have to look exactly
like the industrial labor negotiations of 40 years ago to be
effective, and I do not think that is right.
But the reason for my pessimism is that we are not sure. If
you ask me to put a number on what the passage of EFCA would do
to the Gini coefficient, I have no idea. If you ask me what
would comprehensive health care reform do to the number of
uninsured, I can be quite exact and highly optimistic about
that.
Ms. DeLauro. I am going to yield back my time, Mr.
Chairman, because I am going to the Budget Committee, where we
are going to do battle to see if every time we get to thinking
about where the cuts ought to be made, it winds up in the
nondefense discretionary portion of the budget, which is where
you have health care and where you have education and some of
the issues that might in fact make a difference in people's
lives. So thank you, Mr. Chairman.
Thank you, Dr. Krugman.
Mr. Krugman. Thank you.
Mr. Obey. Mr. Bonner.
Mr. Bonner. Thank you, Mr. Chairman.
Dr. Krugman, I am going to steer away from your testimony
today, because I feel like some of my colleagues will take an
opportunity to talk to you about that. I would like to focus on
a couple of articles that you wrote recently, one February 1st,
Protectionism in Stimulus; and on March 16th, A Continent
Adrift.
Let me give you a quick update on my thoughts and then,
more importantly, I would like to hear from you on yours.
Last week, many of our colleagues on both sides of the
aisle took the opportunity to rush to the microphones and I
know sincerely, but, nevertheless, express their outrage and
dismay over the fact that there were bonuses that had been
allowed for some of the small number of employees at AIG. The
President was outraged over it and we were all outraged over
it, although we never really answered the question who actually
instructed Senator Dodd to take the language out of the
conference committee that would have addressed this issue in
the stimulus bill.
One of the reasons I opposed the stimulus bill was an easy
one for me, but a harder one to explain to some of my
colleagues, and that was there was also a Buy American
provision in it. Now, every member of this Committee is
American; probably every person in this room is American; and
we are all for buy America to create American jobs. Yet, the
example I used with a steel caucus hearing was we have a
company in Germany, ThyssenKrupp, that invested, two years ago,
$4,500,000,000 of their money to come to the United States to
create jobs in America, 20,000 construction jobs right. They
actually were looking at Louisiana, but we ended up bringing
them to Alabama, so we were grateful to have them come. These
are good paying jobs with good paying health benefits. They
will replace lower wage jobs in the textile industry and timber
industry jobs, many of which have gone offshore.
And, yet, one of the provisions--and I talked to Secretary
Summers about this--was that, in an effort to wrap our arms
around American jobs, we ended up saying, okay, you can come
invest $4,500,000,000, create 20,000 construction jobs, 2700
permanent jobs, but, by the way, you cannot sell any of the
steel that you happen to manufacture to the U.S. Department of
Transportation because that is not American, even though those
jobs and the product would actually be finished here.
So since you have opined in a couple columns about what is
going on in Europe and specifically also about the Buy American
provision in the stimulus, I would like for you to help me
understand, from your perspective, do we run a risk when we
rush to judgment about an issue and hold up something as
popular as Buy American in setting off a trade war and building
walls of isolationism, much like we did in the 1920s and 1930s,
do we run a risk of actually doing more harm than good with
policies like that?
And I apologize for the confusion of the question.
Mr. Krugman. No, it was not confused at all. This is
exactly the issue on which I have to talk at my next engagement
today.
Let me say where we are. The problem with protectionism of
any form--and the Buy American provision is not the grossest
form of protection, but it is certainly a step in that
direction. The problem with it is that it is very hard to undo.
The relatively open world trading system that we have now has
been a very good thing for the world. Less so, I would say, I
think not so much about American workers, where there are some
ambiguous effects, but for the poorest countries. When someone
asks me why is relatively free trade important, my answer is
think about Bangladesh. Think about the poorest countries,
which cannot survive unless they can export their products.
That relatively open system we have now took 70 years to
create. After the highly protectionist responses that the world
undertook during the Great Depression, it took generations of
painstaking, slow negotiations to basically get back to where
we started. And if you smash it apart right now, putting Humpty
Dumpty back together again might take another three
generations. So that is the reason to be extremely cautious
about it.
You do not want to say, I think it is incorrect to say that
protectionism caused the Great Depression or even to say that
protectionism would necessarily make our current crisis worse.
Particularly given that the United States is being more
aggressive in grappling with this crisis than the Europeans
are, the temptation to say, well, let us keep the benefits of
our stimulus at home is real and not foolish. But if you think
about the costs, think about what could happen if we break up
the system which has been so hard won, those are very serious
to worry about.
Mr. Obey. The gentleman's time has expired.
Mr. Jackson.
Mr. Jackson. Let me thank you, Mr. Chairman, and let me
also apologize to my colleagues who may not know that I was
here on time at the appropriate beginning of the hearing. But
Congresswoman Lowey and I are trapped in a dueling hearing
across the hall, and I wanted to make sure that they were
understanding of why the queue is reflective of the way it is;
and I thank the Chairman.
Professor Krugman, I know that you have concerns about the
public-private partnership presented by Secretary Geithner on
Monday. A number of us do. And some of the concerns that you
have articulated are clear to many of us, and there are certain
hazards associated with the public-private partnership offered
by the Secretary.
But I wanted to present to you another concept of public-
private partnerships written about by your colleague, Bob
Herbert, at The New York Times just a week or two ago.
The Congress of the United States has been trying, and a
number of States have been trying, to attract more private
investment in public works projects. A little different than
the bank rescue plan, but, nevertheless, there is an
acknowledgment by this institution that there is sufficient
private capital available to build and expand the domestic
economy and the domestic job creation base by attracting
private capital to public works projects if the private
investors can find a way in a public works project to get their
profit out of the project. Obviously, combining the best of
public governance with the best of private experience, there is
a potential match made in heaven.
Bob Herbert specifically talked about a greenfield airport
outside of my congressional district that could provide an
opportunity to create, initially, 15,000 jobs, but, upon its
final expansion, nearly 350,000 jobs to the local economy. No
public works project does for an area what an airport does. An
airport comes, for example, the accelerator and the multiplier
effect: Hyatt, Hilton, UPS, Federal Express, DHL, etc.
Could you distinguish for the Committee the difference
between many State efforts, many local efforts, including
Federal efforts to encourage private investment in public-
private partnerships from the kind of public-private
partnership that Secretary Geithner articulated with respect to
banks and share with us some of the hazards associated with the
latter?
Mr. Krugman. Thank you. There is no problem with bringing
the private sector in on a project; it is a pragmatic issue. If
the financing can be more easily arranged, if the expertise
that private firms can bring to a project can be best brought
in not simply by hiring them as a contractor, but by making
them a stakeholder, that is fine. If you go through American
economic history, you can find that we have done things in a
variety of ways. The Erie Canal was a straight public works
project, but the building of the Transcontinental Railroad was
essentially what they did not call at the time, but was a
public-private partnership, where land grants were used to
encourage the railroads to do the job.
The issue about the PPIP really has nothing to do with
these things. My way of understanding what Secretary Geithner
has presented is that it is, in essence, the same plan that
former Secretary Paulson presented six months ago. It is really
a proposal to have the taxpayer buy up a bunch of assets at
more than anyone in the private sector is currently willing to
pay. It is disguised a little bit, or at least it is made
obscure by the complexity of the financing scheme and by the
fact that the headline number of public investment is not going
to be quite as large.
But what it really does is it gives the private equity
investors, in effect--I am being a little inflammatory here,
but it basically bribes public investors to go out and buy the
toxic assets. It offers them what is in effect a large put
option because the FDIC is guaranteeing debt which is 85
percent of the total and, if things go bad, the investors can
simply walk away. So if the investments turn out to be bad,
there is a strong element of heads, they win, tails, the
taxpayer loses.
Now, that is being defended by Treasury on the grounds that
these assets are in fact being greatly undervalued, and that
what we really need is a large subsidy to make people buy it.
But it has nothing to do with it. Buying up toxic paper from
troubled banks is not at all like building an airport.
Mr. Obey. The gentleman's time has expired.
Mr. Rehberg.
Mr. Rehberg. No questions.
Mr. Obey. Mr. Honda.
Mr. Honda. Thank you, Mr. Chairman.
It is a pleasure to listen to the testimony, and your
prepared statement, for a person who did not study economics,
is easier to read for me.
The question I have is there is a lot of debate on
measuring economic growth and measuring inequities in our
system within our population. The measure that we use, from
what I hear, is GDP. Are there other measures that would be
more precise that would create a greater contrast in what you
are trying to talk about using GDP? Is there another way of
doing that so that it is more precise and perhaps even more on
point?
Mr. Krugman. Congressman, I am tempted to act professorial
and say that is a good question, which is a way of playing for
time because you do not actually know the answer yourself. What
I would say is, first off, no serious economist believes that
GDP is a sufficient measure of economic success. We all know,
every principles of economics textbook, including my own, has a
couple of pages on what GDP does not do; and simply having a
higher GDP does not necessarily tell you the actual improvement
in the quality of life.
It helps to use some measure which comes closer to the
experience of the typical family, which is why people like
myself often focus on things like median family income. But
even that misses quite a lot. Whether there is a single measure
that can capture all of what we want to talk about is highly
dubious. People have tried to do that; they always end up being
somewhat arbitrary constructions.
To take the example if we are comparing the United States
and France, we have substantially higher GDP per capita. We
have approximately the same labor productivity. The difference
is partially that they have higher unemployment, but largely
that they just take longer vacations that we do. How much of
that is a loss and how much of that is simply a different
choice?
For what it is worse, gross changes in GDP almost always
reflect comparable changes in any measure of the quality of
life. There is no question that if you have country A, which
has twice the GDP per capita of country B, country A is going
to be a happier country.
But I think you are asking too much to have a single
number. We use GDP, we use a few other measures, but then we
are not so much presenting a number as telling a story: what is
it like in this Country; what is it like in our society.
Mr. Honda. I was not looking for a single metric, I thought
maybe there might be a series of metrics out there that can be
used to contrast one to another.
Mr. Krugman. Certainly, we have life expectancy, infant
mortality; we have survey results about life satisfaction,
which tell you something about how people perceive their lives;
we have measures of household security or lack thereof. All of
these things come together. There is not a whole lot of
difference between rankings of countries by simple GDP per
capita and rankings by these others, but there are some
important difference. Particularly, more equal, less insecure
societies look better, rank better on most of these measures
than looking at GDP would have told you.
Mr. Honda. Thank you.
Mr. Obey. Ms. Lee.
Ms. Lee. Let me first just thank you for being here, but
also thank you for your testimony, Dr. Krugman, and also how
you kind of break down economic analysis as it relates to
public policy. I always read your columns and your articles,
and looking at your testimony today, it is very consistent with
ordinary folks being able to read and understand what is taking
place in the economy and what we need to consider as we move
forward.
I wanted to just mention one of your comments in your
testimony. You talked about the poverty rates. A boom year was
about 12.5 percent. I would have added, in addition, for people
of color, for instance, for African-Americans, it was 24.5
percent to 27.9 percent; for Latinos, 21.5 percent to 27.1
percent.
I wanted to ask you how--and we understand the environment
we are currently in in terms of the consideration of race. Race
and class have always been a big issue in this Country, and I
want to find out, as it relates to the poverty rates now, how
you see race. Is it still a factor? What would you say would
account for these huge gaps? I mean, 12.5 percent is bad
enough, but when you go to 24 to 27, 21 to 27, that is twice as
bad. So by leaving out communities of color, people of color,
does that send a different type of message that race is not a
factor anymore in our economic strategies, or how do you see
this at this point with, quite natural, President Obama as
President?
Mr. Krugman. I think there is only so much I can say here.
One is that, clearly, there are large racial differences in
poverty rates in income. While we like to emphasize that a
majority of the poor in the United States, contrary to popular
impression, are not in fact African-American, certainly, the
poverty rates are much higher among African-Americans. And it
would be clearly foolish to suppose that, simply because we
have finally had an African-American President, that race has
ceased to be an issue in America, it is very much still an
issue, very much still a large part of our social scene, of our
economic scene.
The causes of the racial differences are probably complex.
I, for one, do not believe that discrimination has ceased to be
a factor. I do not believe that we wiped away all of our
centuries of history; I believe it is a real issue. There are
also social issues. There are simple persistent issues.
Referring to some of the remarks we had earlier, we are not
a society of perfect social mobility. There is actually a great
deal of hereditability of economic status. And the fact that we
had undeniably vast discrimination in this Country not that
long ago continues to color our income distribution, our
poverty rates today.
Now, many of the things we can do to mitigate suffering, to
mitigate poverty can be color-blind even though we are aware of
the issues of race. Universal health care is going to be good
for people. Probably the biggest beneficiary, certainly rates
of insurance are highest among African-Americans. But that does
not mean that you have to think about that in devising the
program; you simply have universal coverage and it serves those
most vulnerable especially well. Other things, certainly we
need to take them into account.
I would agree with the President, race is our original sin
in this Country. We have made far more progress in coming to
terms with that over the past 50 years than many would have
imagined, but we have certainly not come pass it.
Ms. Lee. Thank you very much. The second question I have is
with regard to income inequality and this recent unethical and
immoral and probably, possibly criminal behavior by many of the
Wall Street firms as it relates to the bonuses, I have a bill,
it is the Income Equity Act, and what I am trying to do is
close some of these loopholes that would allow these unlimited
kinds of bonuses. But what this bill would do would be to only
allow the deduction of $500,000 or more, 25 times the pay of
the lowest wage worker to receive a Federal tax deduction.
Mr. Obey. Could I ask you to be very brief in the answer?
The gentlewoman's time has expired.
Mr. Krugman. Yes. I cannot respond without knowing much
more than I do about the bill. I am all in favor of seeking
ways to limit this and certainly some of the deeply unjust tax
privileges that some people in the financial industry have
received, but beyond that I cannot go.
Ms. Lee. Thank you very much.
Mr. Obey. Ms. Roybal-Allard.
Ms. Roybal-Allard. Thank you, Mr. Chairman.
Mr. Krugman, in your book, Confronting Inequality, you
state that the principle of equality of opportunity, not
equality of results, is a largely fictitious distinction. Could
you elaborate on what you mean by that?
Mr. Krugman. Yes. It is often stated that, well, what we
want is equality of opportunity, and that does not mean
everybody has to end up in the same place. But if you have a
highly unequal society, as we do, the children of those who do
well are given a great advantage. The children of those who do
poorly are put at a great disadvantage.
And in the book, The Conscience of a Liberal, I cited the
studies on educational attainment versus socioeconomic status,
where it turns out that high-scoring students as of eighth
grade, from the bottom quartile, measured by socioeconomic
status, are less likely to graduate college than low-scoring
students from the top quartile on socioeconomic status.
Loosely speaking, that rich dumb kids are more likely to
make it through college than poor smart kids. And that is
telling you that we are a society in which, whatever we may
like to imagine, we are not a society that has anything like
equality of opportunity; that there is strong passing down
through the generations of social and economic status.
Ms. Roybal-Allard. You go on also to say that this high
inequality imposes serious costs on our society that goes
beyond the purchasing power, and one of the things that you
give an example is how it corrupts politics. Could you
elaborate on that and maybe given some other examples?
Mr. Krugman. Yes. We certainly see that our political
system is utterly democratic on paper and much less so in
reality; that we can see--and I think everyone on this panel
knows better than I do--the role of money, of influence, and
simply of voice; that in a society where many people are poorly
educated, scraping by, their voices are not heard in our
political system. It undermines. People who have extreme views
would say that we are a democracy in name only, and are really
an oligarchy. I think we are better than that, but there is
certainly a grain of truth to that.
My colleague, Larry Bartell, in the Politics Department in
Princeton, has shown that really the bottom third of the U.S.
population is entirely ignored by the political process, that
the views of the poorer constituents, even lower income working
people are essentially ignored by the process. And that is not
the Country we should be.
Ms. Roybal-Allard. Is my time up, Mr. Chairman?
Mr. Obey. No. You have one minute left.
Ms. Roybal-Allard. Okay.
So basically what you are saying is that although we, as
Americans, like to think that, in this Country, we have equal
opportunities, that basically that is a fantasy and that not
only that we do not have equal opportunities, but that it is
reflected in equal results that negatively impacts the ability
of people to move upward in our society?
Mr. Krugman. That is right. We still see ourselves as a
society of Horatio Alger stories. And they do happen, but they
happen much more rarely than people imagine. And, for what it
is worth, we are less a society of Horatio Alger stories at
this point than some other advanced countries. The chance of
somebody born in the bottom quintile of making it into wealth
or even substantial affluence is less in the United States than
in Canada or Finland, largely because of things like the
inadequacy of our health care system.
So there are opportunities. We are not a caste society, but
we are not the kind of wide open society that we hold up to
ourselves as an ideal and sometimes imagine that we actually
fulfill and practice.
Ms. Roybal-Allard. And, as a result, we are all impacted by
this inequality, regardless of where we are on the income
standard.
Mr. Krugman. That is right. We are at the level of value
judgments at some level, but we are more--let me just say one
thing. We are certainly wasting a great deal of human
potential. Those smart kids from the bottom quartile who do not
manage to make it through college essentially because they are
so disadvantaged, that is talent that we could use, that we
need.
Ms. Roybal-Allard. Okay. Thank you.
Mr. Obey. Thank you.
Mr. Ryan.
Mr. Ryan. Thank you, Mr. Chairman.
I appreciate it. I enjoy reading your column during the
week and I have enjoyed your books. I think you have provided a
lot of guidance for those of us who are trying to deal with a
lot of these issues.
I represent a district that is in Northeast Ohio,
Youngstown, Akron, who have been hit in a major way not just
recently, but I think over the course of the last 25 or 30
years, and you can see where our local economy is based on what
has happened just in the past few months. We see a General
Motors plant who gets rid of a third shift, gets rid of a
second shift, and three or four days later the seat
manufacturer lays off a couple hundred of people, and a few
days later the logistics company lays off a few more people,
and Delphi, right down the line.
So my question is in two parts. One is an issue that I
think the Secretary of the Treasury kind of tipped his hat at a
little bit early on, the issue of China, currency manipulation
in China, what your thoughts are on that and maybe how we can
address that as a Congress and from the Administration
perspective.
And then, also, as I stated earlier, how the ripple effect
of manufacturing and how manufacturing leads to more job
creation than the financial sector. I know you mentioned
earlier about going from 4 percent of our GDP to 8 percent of
our GDP is finance, and that would be healthy if that gets
reduced back to 4 percent. So something has got to fill that
void. Is it manufacturing? How can we put together a good
comprehensive manufacturing policy in the United States?
So China currency and a manufacturing policy. And you have
four minutes to solve that.
Mr. Krugman. Right. China currency policy. I think I was
struck by Secretary Geithner's excessive clarity. It seemed to
me that that was a case where a little bit of Greenspan clouds
of words was appropriate. It is a very difficult issue. Of
course China is manipulating its currency. They got those
$2,000,000,000,000 of reserves somehow.
The question is what you want to do about it, and that is a
very tricky issue, especially given that while, on the one
hand, we do not like those Chinese exports competing with U.S.
goods, although that is not as great an issue as people
imagine, on the other hand, we do not want them abruptly
dumping all their dollars. So it is a trick issue for which I
have no good answers. It is just one of those things that one
hopes just fades away.
Mr. Ryan. Is now a bad time to try to address that?
Mr. Krugman. Probably now is a bad time. Let me just say
right now the woes of manufacturing--and I think this is the
crucial thing right now--this is not that U.S. jobs are being
stolen by other people. Manufacturing is in a catastrophic
state around the world. It is collapsing everywhere because of
the severity of the economic slump. Just this morning we had
the news that Japan's exports have fallen 50 percent over the
past year, just catastrophic collapse in their exports of
manufactured goods. Same thing is happening to China. Same
thing is happening to Germany.
So the urgent thing that we need right now is not how can
we get some slightly bigger share of this global manufacturing
pie, but how do we stop this--I am going to have trouble with
my metaphor here, but how do we stop this pie from shrinking to
insignificance for all of us. There are longer term
manufacturing issues, but right now what we need is economic
recovery. We need to do whatever we can do to get it. And
manufacturing is on the leading edge, is paying the biggest
costs from the slump and would then be the biggest beneficiary
if we can get a recovery.
Mr. Ryan. Some people kind of pooh-pooh the idea that a
green revolution can lead to resuscitating manufacturing in the
United States. We have a lot of little machine shops that are
making the bolts that go in the windmills. I mean, from a
policy perspective, is that a realistic expectation that all of
this investment in green technology will lead to reviving
manufacturing?
Mr. Krugman. It would help. I think it is unrealistic to
expect manufacturing ever to be the same share of GDP that it
was 30 years ago, just as it is unrealistic to expect us ever
to go back to a Country where a large proportion of the
population is farmers. There is a transition; we have moved,
everyone has moved towards becoming increasingly a service
economy. But manufacturing is especially depressed right now.
It could come back significantly.
The whole green investment, green spending is real. I have
not been able to form any judgment of my own about how big it
will be ultimately. It certainly will be a factor, but how big
I do not know.
Mr. Ryan. Thank you.
Thank you, Mr. Chairman.
Mr. Obey. I promised Dr. Krugman [remarks made off
microphone]. So I would simply give Mr. Tiahrt one minute for
whatever summary thoughts he might have.
Mr. Tiahrt. Thank you, Mr. Chairman.
And thank you, Dr. Krugman, for being with us. It has been
very enlightening. I enjoyed your conversation and your
positions. I would disagree with your colleague about the
poorer class or the lower class being ignored by the political
process. I know that Ms. Lee and Chairman Obey and others here
pay a great deal of attention to it, and I would argue with him
that they do have access to Medicaid, EITC, public schools,
unemployment, and they do vote; and we all realize that, so we
pay a lot more attention to them than your colleague may
realize.
I just want to conclude by saying that my concern in the
direction that the Country is going ignores the fact that a
rising tide raises all boats, and when we have a strong
economy, even those who do not have access to college have
access to opportunity. And if we can provide access to
opportunity, those that do not complete college--Bill Gates
would probably be the most large example--but others do take
that opportunity and bring these ideas to the marketplace, and
it is those private sector jobs that help us keep the lights on
in the Federal Government and at the State and local
governments.
So my concern is how do we raise the tide. And your input,
I think, has helped give me a different perspective on some of
the things that we are looking at. Thank you very much.
Mr. Krugman. Thank you.
Mr. Tiahrt. Thank you, Mr. Chairman.
Mr. Obey. And I guess all I would say is that I would like
to think that in all cases a rising tide lifts all boats. The
problem is that, as has been said by others in the past, at
some times in our recent history it appears that a rising tide
has raised only all yachts.
Let me say that I appreciate your comments today. I think
it is important to hear what you said with respect to the
stimulus package, when you indicated that there is no great
certainty that the need for stimulating the economy will
evaporate within a year and a half. I certainly do not think it
is going to. I wish I did.
With respect to your acknowledgment of the difficulties
that we have in trying to reduce inequality, I guess all I
would say is that I do believe that, whether directly or
indirectly, we can at least impact that around the edges by
what we do to enhance educational opportunity, and by what we
do to strengthen the bargaining position of workers at the
bargaining table. We certainly can impact their welfare by the
shape and nature of the tax code and we can certainly
strengthen the safety net for those who do not do well in the
economy through actions such as universal health care and
pension protection and the like.
If you would like to comment for a minute before you leave,
the floor is yours.
Mr. Krugman. Yes, Mr. Chairman, I would very much agree.
The fact that you do not know just how much effect you are
going to get from a policy is not a reason not to do it if you
think it will move things in the right direction. And I believe
that education enhanced opportunities for labor to organize
would help reduce inequality.
I think I am thinking a little bit as an author when I
wrote my last book but one. I put health care first because
that was the one where I thought I could promise some very
specific results, and I put reducing inequality as a more of
here are some things we ought to try, and they would probably
all help, but I do not know how much, and that is not to say we
should not do them.
We can do a lot better than this. I think the main point is
that we have a tremendously vital private sector. We have
entrepreneurship; we have innovation. What we do not have is an
adequate way of making sure that all Americans are benefitting
from what that private sector creates, and we can do much
better at that than we have been doing. Thank you.
Mr. Obey. Amen to that. Thank you very much. Good luck at
your next engagement.
Mr. Krugman. Thank you.
----------
Wednesday, March 25, 2009.
RAISING WAGES AND LIVING STANDARDS FOR FAMILIES AND WORKERS
WITNESSES
KEITH HALL, PH.D., COMMISSIONER, BUREAU OF LABOR STATISTICS, DEPARTMENT
OF LABOR
JOAN FITZGERALD, PH.D., DIRECTOR, LAW, POLICY AND SOCIETY PROGRAM,
NORTHEASTERN UNIVERSITY
PHAEDRA ELLIS-LAMKINS, CHIEF EXECUTIVE OFFICER, GREEN FOR ALL
Mr. Obey. Let me next call our second panel. First, Dr.
Keith Hall, who is currently Commissioner of the Bureau of
Labor Statistics. Dr. Hall has led the Bureau since January
2008, having been appointed Commissioner by President Bush. He
has also served as Chief Economist for the White House Council
on Economic Advisors and the Department of Commerce and
International Trade Commission.
Dr. Joan Fitzgerald, Director of the Law, Policy and
Society Program at Northeastern University in Boston, is the
author of Moving Up in the New Economy: Career Ladders for U.S.
Workers, and has written extensively about models for training
and career advancement in the health care sector.
I understand that Mr. Honda would like to briefly introduce
Ms. Phaedra Ellis-Lamkins.
Mr. Honda. Thank you, Mr. Chairman.
Members of the Committee, I would like to introduce a
personal friend, Ms. Phaedra Ellis-Lamkins. Phaedra hails from
San Jose, California, and is the CEO of Green For All, an
organization dedicated to building an inclusive green economy,
fighting pollution and poverty together. Prior to her position
at Green For All, she was the head of the South Bay Labor
Council and Working Partnerships in Santa Clara County.
She is nationally recognized for creative and innovative
approaches to improving the lives of working families and her
brilliant, charismatic leadership style.
And I do not think I am embarrassing her yet, but I will
get there.
She has co-founded the Partnership for Working Families, a
national coalition to bring the principles of good jobs and
community benefits to local economic development. She fought to
create one of the first community benefits agreements in the
Country, providing community standards for large-scale
development projects in San Jose.
She has been featured in The Wall Street Journal online,
San Francisco Chronicle, San Jose Mercury News, America At
Work, NBC News, and ABC News.
Finally, she serves on the board of the Leadership Council
of California.
She has many other accomplishments that I could name, but,
in the interest of time, Mr. Chairman, let me just extend a
warm welcome to her today.
Mr. Obey. Thank you.
Ms. Lee, I understand you wanted to make a comment?
Ms. Lee. Well, just welcome and congratulations to you.
Now, of course, we share, as the new CEO for Green For All, now
with Van Jones, advising our President and our Country on the
greening of our economy and ensuring that no one will be left
behind. I really thank you very much for your leadership and
for making this transition now. We look forward to working with
you, of course, in Oakland, California also. Thank you.
Mr. Honda. We share good.
Mr. Obey. I am going to forego my opening statement for
this panel because I am informed that we are about to have
three votes beginning sometime after 11:45. This place would
function very well if we did not have to interrupt our work to
go vote, but that is part of the job.
So what I would hope we could do is get each of you to get
your statements in before we have to leave. When we do leave,
we will be gone for about half an hour, I am afraid. So I would
like to squeeze as much in as we can before we leave.
Dr. Hall, why do you not proceed first? Take about five
minutes to summarize your statement.
Mr. Hall. Thank you, Mr. Chairman and members of the
Committee. I appreciate the opportunity to discuss the Bureau
of Labor Statistics' occupational outlook information with you.
I would like to provide a very brief overview of the current
economy and then discuss long-term employment trends through
2016. In light of the Committee's interest in health care, I
will address this field specifically. Finally, concerning a
topic of current intense interest, green jobs, I want to
briefly discuss the challenge of measuring the number and
characteristics of these jobs.
As you know, the Nation is in the midst of a sharp and
widespread contraction of the labor market. Since the start of
the recession, 4.4 million payroll jobs have been lost and the
unemployment rate has increased from 4.9 percent to 8.1
percent, the highest level in over 25 years.
Job losses have occurred in nearly all major industry
sectors, and employment has grown only in health care, private
education, and government. Unemployment is up among all major
demographic groups, and the number of people working part-time
and voluntarily has jumped to 4 million. Job losses have
occurred throughout the economy, as four States now have an
unemployment rate above 10 percent.
The BLS prepares long-term national projections every two
years, including the labor force, industry output, and industry
and occupational employment. The most recent projections were
published for the 2006-2016 period. We rely on data from a
number of BLS programs, including the Current Employment
Statistics, Occupational Employment Statistics, the Current
Population Survey, and the Producer Price Index. We also use
data from other Federal statistical agencies, primarily the
Census Bureau and the Bureau of Economic Analysis.
I want to first note that the 2006-2016 projections were
completed before the current recession. The impact of the
recession and financial market turmoil on the long-run
structure of the economy may not be known for some time, and
may well impact the long-term trends that are the focus of our
projection analysis. For example, we do not yet know if recent
large declines in retirement wealth may impact future labor
force participation rates of older workers.
To put the occupational projections into context, let me
briefly review the broad trends. We expect growth in the labor
force and total employment to slow, and the decline in
manufacturing employment and shift toward services employment
to continue. We expect that employment in manufacturing,
mining, and the Federal Government and utilities will all
decline. All other major industry groups are projected to gain
jobs, with the most rapid job growth expected in health care
and social assistance, professional and business services, and
educational services.
Total employment is expected to growth 10 percent over the
decade, resulting in 16.5 million new jobs. The two groups with
the largest employment in 2006, professional and related
occupations, and service occupations are also expected to grow
faster than other groups, each increasing by 17 percent. Both
include occupations within the large and fast-growing health
care and social assistance, and professional and business
services industries, such as registered nurses, home health
aides, and computer software engineers.
These two groups also represent the opposite ends of
education and earnings ranges. Many occupations in the
professional and related group pay wages above median for all
occupations and require higher levels of education or training,
while many service occupations pay lower wages and require less
education and training.
So far I have mentioned only job growth; however, job
openings arise not only when new jobs are added to the economy,
but also when existing jobs become permanently vacant, such as
when workers retire. These replacement needs are expected to
generate more than twice as many job openings as job growth
alone. The retirement of the baby boom generation will create
many replacement openings, where replacement needs will be
significant in any large occupation, even some that were not
expected to grow. Also, many rapid growing occupations have
relatively low employment and will, therefore, add relatively
few job openings.
When the two sources for job openings, growth and
replacement, are added together, a different picture emerges.
Service occupations where replacement needs are high are
expected to generate the most job openings. And although
professional and related occupations will likely add more new
jobs through growth than service occupations, it has lower
replacement needs and will therefore generate slightly fewer
job openings.
Increasing demand for health care services will generate
significant employment growth throughout the health care
sector. The primary driver of this growth is an aging
population. Advances in medical technology will continue to
improve the survival rate of severely ill and injured patients
who will then need extensive therapy and care. At the same
time, cost containment policies will generate faster than
average growth and demand for health care workers who assist
health care practitioners and have lower training requirements.
BLS produces comprehensive employment wage data for 670
industries and over 800 occupations. While we can identify some
of the industries and occupations that are likely to have green
jobs, most green activities either cut across industries and
occupations or account for a subset of activity within an
individual industry and occupation category. For example,
retrofitting buildings to increase energy efficiency currently
falls in the construction industry, but likely support only a
small fraction of the current 6.6 million construction jobs in
the U.S.
In closing, I just want to express my appreciation to the
Committee for inviting me to be part of the distinguished panel
today, and I want to thank you for your support of the Bureau
and its programs, and I am looking forward to working with you.
Mr. Obey. Thank you.
[The information follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Obey. Dr. Fitzgerald.
Ms. Fitzgerald. Yes. Thank you, members of the Committee,
for having me here today.
I would like to talk about the health care sector and its
potential for creating middle class jobs for people who are
already in the sector.
There are three interconnected issues here. The first one
is improving the quality of care; the second one is improving
skills of the workers who are in the profession; and the third
is improving wages.
In 2006, I published a book called Moving Up in the New
Economy, where I examined career ladder programs in health care
and several other sectors throughout the Country. They were led
by community colleges, community organizations, unions,
employers, and combinations of those groups. I identified two
types of career ladder strategies: one that creates ladders
within an occupation that already exists, and others that help
people in lower levels advance to higher levels.
But before I talk about those, I would like to also mention
simply the importance of raising wages, irrespective of
training. And let us just take the case of the lowest paid
workers in these occupations, that is, home health care workers
and those who work in long-term care, either as something
called home health aides or certified nursing assistants.
Basically, these are jobs that take anywhere from 6 to 12 weeks
of training.
They are very poorly paid. People in these occupations get
very little respect on the job and, as a result, the turnover
rate is very, very high. That high turnover rate affects the
quality of care. The person who is coming in to take care of
your parent, whether in a nursing home or in their home, when
they leave and that job turns, you are also losing the person
who knew something about the person they are caring for and
their special needs.
So what we find is, by increasing wages, we decrease
turnover, and that, in and of itself, helps to improve the
quality of care.
But let us look a little bit at some of the strategies. One
is to create tiers within occupations. If we look at certified
nursing assistant, the next tier up is to become what is called
a licensed practical nurse, in some States a licensed
vocational nurse.
For someone who is working full-time, raising a family, and
going to school, it is an 18-month path; and what happens is,
if a person--and this is often the case--trying to make that
advance does not make it, she has nothing to show for it, she
is still a CNA. So the idea is to create tiers within the
occupation so that you recognize increases in skills.
There are many in my book that I talk about, programs like
this throughout the Country. There is one problem with them,
though: they are usually developed by an employer, and if you
become a CNA-2 or a CNA-3 at one place of employment, that is
not a portable credential that you can take along with you.
And the other problem is because they are working in
occupations that are, for the most part, subsidized by
government funding, there is not enough money in the system to
really raise their wages out of the poverty track. There is
potential here, though, but we have not achieved it yet.
Let us move on quickly to career ladders. In theory, what
we have is a career ladder that starts at the certified nursing
assistant, moves up to the licensed practical nurse, then moves
up a step to the Associate degree registered nurse, the
Bachelor's degree registered nurse. You could take it up to
Masters and Ph.D. in nursing, for example. In practice, the
most likely--and this is a very difficult career ladder jump--
is from the CNA to LPN.
I have looked, as I said before, all around the Country.
Everything you need to know about how to do this you can learn
from AFSME's District 1199-C Training and Upgrading Fund in
Philadelphia. There is simply nothing else comparable in the
Country. It serves over 10,000 workers a year; it is operated
mostly on Taft-Hartley money that the employer kicks in 1.5
percent of payroll; and it is the Nation's only union-run LPN
school.
But because the union also receives grants from the
Department of Labor and other government funding sources, they
can serve people in the community as well.
I could go on for some time about the features of the
program that make it great. I think one of the things that is
unique among this program is the three people who started it--
Henry Nicholas, Cheryl Feldman, and the late Jim Ryan--have
been with the program for all of its 35 years and have really
been able to adapt it. But here is a case where a certified
nursing assistant can almost double her wages by moving on to
an LPN.
But one of the problems facing these kinds of programs and
any kind of advancement program for people in the nursing
occupations is the shortage of nursing faculty. And there have
been programs throughout the Country by different States trying
to address this shortage, but here again the problem is a wage
gap. A Bachelor's degree or even an Associate degree nurse
makes about $72,000 a year, and it is about $62,000. It is less
than that for a Master's degree or Ph.D. trained nurse working
in a university. So you are a nurse; what decision are you
going to make in terms of where you are going?
So that has to be part of the whole picture of how we
improve career ladder opportunities in nursing. And we have
tried to deal with that once at the Federal level with the
Nurse Education, Expansion and Development Act, but the
legislation never passed. It has been reintroduced by Durbin.
I could go on and tell you about several other types of
programs not only in nursing, but in behavioral health,
surgical technician, orthopedic technicians, but you can read
about those later. What I want to point out is how
contradictory the Federal policy is on this.
On the one hand, we have cost containment guidelines for
Medicare and Medicaid, and we know there is a lot of corruption
in the system that needs to be fixed. But those cost
containment restrictions are also responsible for maintaining
this low wage industry.
Then, on the other hand, we have the U.S. Department of
Labor creating these special pools of funds to improve worker
training, and these demonstration projects cannot compensate
for the low wages that exist in the sector.
Then, if we had a third hand, we could say the other thing
we do is use H1-B funding to bring in nurses trained from other
countries, so essentially we are outsourcing the education and
training of nursing and other health technicians in this
Country.
So, to close, I would argue that we have to set as a
national goal not just the expansion of these various small
programs here and there and training, but an ideal that all
positions in the health care field pay at least a good
paraprofessional salary and provide benefits to workers; and it
is only by linking those two goals that we will really create
middle class jobs in the health sector.
Thank you.
Mr. Obey. Thank you.
[The information follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Obey. Ms. Ellis-Lamkins.
Ms. Ellis-Lamkins. I am going to try to be thoughtful of
your time also, so, Chairman Obey and members of the Committee,
thank you for inviting me here. I would also like to say a huge
thank you for the introduction from both Mr. Honda and Ms. Lee.
Certainly having advocates like them makes it just an exciting
trip to be here, but really because of their strength and
leadership, we are very proud of them and proud to be their
constituents; and to get to be both of theirs is a true honor.
I am here on behalf of Green For All, a national
organization dedicated to moving people out of poverty through
the green economy. Basically, we think this is a moment in
history that we are going to look back and judge ourselves by
how we behaved, and the reason is because the economy is going
through a transformation. And in the same way that technology
transformed the economy, the greening of the economy, the need
to conserve energy, the need to save money is going to
transform this economy.
The real question for Green For All is will we use that
opportunity to move people of color and low income people into
this economy, and our belief is that if we are purposeful, we
can be sure to make sure that we use this economy and this
changing of the economy to make sure people who are often left
out are allowed to become part of the economy. So what we are
focusing on is specifically green collar jobs. And green collar
jobs are well paid, career track jobs that contribute directly
to preserving or enhancing environmental quality.
So some people ask us, well, does that mean a green job is
where someone uses a broom and is a janitor in a clean green
building, is that a green collar job? We say, no, that is a
poor job that pays someone; it does not pay someone well. What
we are really looking at is what are quality jobs that also
make the environment better.
So the question really is green jobs, why now? Well, two
reasons. First is the fiscal and the financial crisis. The
second is the crisis of global climate change. And I think it
is said best by President Reagan's U.S. Federal Reserve
Chairman, who said that you can be sure that if nothing is
done, the economy will go down the drain in the next 30 years.
Now, for us it is not polar bears that will be the biggest
victims of global warming. People will be the biggest victims
of global warming; ourselves, our children, and our
grandchildren. At Green For All, we think there is a solution
to these two problems: to build a green economy strong and
inclusive enough to lift people out of poverty; to in effect
fight poverty, pollution, and global warming at the same time.
We have to be able to create good jobs in basic green
industries: renewable energies like wind and solar, advanced
biofuels, green building, transportation, waste management,
water conservation, and environmental remediation. And we have
to be able to recognize that the pathways that these present
really will allow the end of a pollution-based economy.
I want to focus on four simple truths about green jobs.
First, the job creation potential is enormous. I have to be
honest. When we looked at this, we said, well, where are the
green jobs? Are there really green jobs that exist anywhere?
And what we found is in fact there are, that a broad range of
studies have demonstrated that the renewable energy sector
generates more jobs per megawatt of power installed, per unit
of energy produced, and per dollar of investment than the
fossil fuel-based energy sector.
What we look at is things like waste management. Every time
we throw away recyclable consumer waste or building materials,
we are throwing away jobs that could have been created. What we
have been doing is looking across the Country, because we said
we know it is not just California, and what we are finding from
the way that we get rid of waste to the way the BeltLine is
being built in Atlanta is that there are some clear examples of
quality green jobs being created.
Second is that green jobs are not just out in the science
fiction movie somewhere, that in fact they are real jobs that
we can point very specifically to. When we look at those types
of jobs, what we are really looking at is will it actually
transform current industries. We sat today with folks who are
looking at training programs. What they have said is, look,
part of what is happening is just the changing of construction.
Part of these jobs will not be new jobs, which is absolutely
true. But there actually will be also industries that create
whole new jobs, from the way paper is done to looking at window
retrofitting. So we are very interested in that.
Three, green jobs are often middle skilled jobs requiring
some post-secondary education, but less than a four-year
college degree. It will not be a handful of scientists and
engineers who build the green economy. Nor will it only be
people who live in certain counties in California and drink too
much Chablis. It will be pipefitters and machinists and
technicians who build the green economy. These can be good
middle-class jobs and, most important, accessible to low
income, low skilled workers.
Fourth, and perhaps most importantly, is these jobs are
difficult to offshore. When we look at the economy's growth,
what we are really trying to figure out are what are the jobs
that will help produce manufacturing, produce job investment
here; and the real potential in green jobs is that it has to be
done. You do not get to retrofit a building in China and send
it back; it has to be retrofitted here. It makes sense for the
materials to be produced here, and it is difficult to
transport.
So, obviously, those are four clear truths about the green
economy. What scares us is the relying on mistaken assumptions:
that fossil fuel energy is abundant and cheap; that pollution
is free; and fast and cheap is the same as quality and
productivity. And we would make five simple suggestions about
what we need to do. And recognizing your time constraints, I
want to just go through them very quickly.
First, smart energy and climate policy have to be the
foundation of an inclusive green economy. We need a bill that
limits greenhouse gas emission and advances aggressive climate
solutions. To ensure that the next economic crisis faced by our
Nation is not compounded by the type of climate crisis and
devastation we experienced during Katrina, where the
insufficient resources of low income families trapped an entire
community, both economically and environmentally, we need a
bill that invests generated revenue to maximize the gain and
minimize the pain for low income people and the transition to a
green economy.
Second, maximizing impact will require policies at a scale
commensurate with the challenge we face. At Green For All, we
have been developing a proposal with partners for a Clean
Energy Corps. I want to also thank those who voted and helped
pass the GIVE Act last week.
Third, job quality in the green economy will not happen
without smart public policies that ensure it. From project
labor agreements to community benefits agreements, high value
contracting standards, it will be clear.
Four, the green economy will not be built without a skilled
workforce. I want to thank you, Mr. Obey, your fantastic staff,
Ms. Lee, Mr. Honda, and the entire Committee for including
$500,000,000 for green job training in the American Recovery
and Reinvestment Act. We will be working to ensure, and we also
would respectfully ask the Committee to look beyond the next
two years of funding provided by the Recovery Act and consider
reserving funds in the next year's appropriations bill for the
Green Jobs Act authorized in the 2007 energy bill and authored
by the Secretary of Labor Solis.
I really want to thank you for giving me the opportunity to
be here, but mostly I want to tell you that I promise this is a
moment in history, and what we all have to decide is how we
want to be viewed in this moment in history. My hope is this is
a moment we will look back and say that this Committee invested
in, believed in the worker in America and believed that
manufacturing and green jobs and preserving the planet was
something that we could all do.
Thank you.
[The information follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Obey. What I am going to try to do, I am going to try
to see how many people I can squeeze in for questions in the
next five or six minutes, before we have to go and vote,
because when we leave I know we will be gone for at least half
an hour, and that will shoot any ability to get questions out.
So if I could ask each member to take about three minutes,
beginning with Mr. Tiahrt.
Mr. Tiahrt. Well, Mr. Chairman, that is trying to cover a
lot of ground in three minutes. Maybe we can get them to return
some of this information as a question.
For example, Dr. Fitzgerald, you have come up with some
projections that are based on a set of ground rules and
assumptions that were not laid out in your presentation. If you
could provide those to me, I think it would help me understand
your projections a little better.
I know that, for example, borrowing $3,000,000,000,000, as
we are going to do this year at the Federal Government level,
is going to have an impact on interest rates unless we print
the money, like we did last week, when the Federal Reserve
printed $1,000,000,000,000. That, in turn, puts more money into
our money supply, which I believe drives inflation. And when
you combine those two you get unemployment. So I am very
concerned about how did you, in your projections, try to adjust
a political climate in the future? Because I think there are
some things that are hard to see. So if you could provide that
to me, I think that would be good.
Dr. Fitzgerald, you mentioned health care having these
different opportunities to create a higher wage scale by
education and by classification within the jobs. But then you
said there is not enough money in the system to raise the
wages. So where do we get this self-eating watermelon? How do
you create this? And I think my concern is if you look at
health care today, 65 percent is privately funded and 45
percent is funded by the Federal Government, either in
Medicare, Medicaid, or VA system. And in every case, every
doctor, clinic, and hospital that I speak to, cost shifts. They
take money they receive from the private sector to cover the
shortfalls of government health care.
So as we expand government health care, there is less money
available to cost shift. And the only option that we see is
what the current doctors in Kansas are doing. Four out of five
of them no longer take Medicaid or Medicare patients, any new
patients. They are trying to let the current ones go through
their life cycle. So if we have less money available to cover
the inadequacy of cost, then we have rationed health care.
So my concern is how do you cover this when we are moving
towards a rationed health care system? How do you increase the
wages for people in health care when there is less money
available?
Ms. Fitzgerald. Well, I would certainly support Dr. Krugman
in his ideas about what we need to do to reform the health care
and reduce administrative costs and put those costs actually
into the delivery of the health care system.
Mr. Tiahrt. Well, one of the things he did not cover is
that a lot of the 14 percent of administration costs are driven
by government regulations. So we have set up this disaster by
imposing these government regulations.
You can go to Wesley Hospital in Wichita, Kansas, who used
to have a whole floor of beds where people could be treated for
problems. Today, that floor has been cleared of the beds and it
is a sea of desks, and it is just to handle the paperwork.
The last thing--and hopefully we can come back and finish
this--Ms. Ellis-Lamkins, I think you are right about your
opportunity in the green jobs, but I think you are wrong in the
premise that it is global warming that is driving it. I want to
submit for the record testimony of 700 scientists. It used to
be 650 scientists. At the last intergovernmental panel on
climate change, 650 scientists signed a report that said that
the earth is actually cooling. It peaked in 1989 and for the
last decade it has been getting cooler.
I know if you talk to Jim Oberstar, he will tell you that
in his district, which is Northern Minnesota, the month of
January it never got above zero degrees Fahrenheit.
So this is actually testimony of 700 scientists that
debunked the claims of global warming. They believe that the
earth is actually getting cooler.
[Clerks note.--The information referred to was supplied and
is retained in the Committee files.]
Mr. Obey. That is only in States populated by Norwegians.
[Laughter.]
Mr. Tiahrt. But that being said, I agree that it is a great
opportunity. You are on to something that I would like to help
with, because I do think there is a wonderful opportunity. For
example, we could build a clean technology coal-fired
electrical generating plant, and with that, in the carbon
sequestration plan, develop a whole new industry related around
algae growth. Algae consumes carbon dioxide, emits oxygen, and
it is very versatile. We can use it to make more electricity,
we can use it for plastics. It has an oil base. You can even
make makeup from it. So it is very versatile, and I think you
are on to something that we need to expand on and create this
opportunity.
Ms. Ellis-Lamkins. Well, I appreciate that, and I would
like to not focus on our disagreements. So whether you think it
is because of global warming or because of business
opportunity, I would like to focus on what we agree on. So what
would be helpful is to have champions of the Green Jobs Act and
to think about how we create some of those opportunities. So I
look forward to a discussion that allows people to move out of
poverty and we will certainly follow up with your staff so that
we can figure out how to make you a champion of those policies.
Mr. Tiahrt. Thank you.
Mr. Obey. We are going to have to go to vote, and we will
return as fast as we can. I would ask members to please come
back as soon as the last vote.
[Recess.]
Afternoon Session
Mr. Obey. I was trying to squeeze several people in, so I
squeezed Mr. Tiahrt down to three minutes. Let me simply go
back to Mr. Tiahrt for another two or three minutes to see what
other questions you might have.
Mr. Tiahrt. Thank you, Mr. Chairman.
Dr. Hall, you mentioned utilities declining, if I
understood you correctly, in the number of jobs. I guess if you
combine that with Ms. Ellis-Lamkins' move to increase green
jobs, many of those would be in the area of utilities. And I
have often thought we could do simple things like they do in
Germany, where they have net metering, and that would encourage
people to go out and produce electricity either through solar
panels or wind generators. In Kansas we are very interested in
wind generators because we have a continuous south wind.
Kasaw [phonetically], in the Oglala Sioux Indian language,
means people of the south wind, and, believe me, we are the
people of the south wind.
So I think there is actually, in the utility sector, unless
you categorize some of those as manufacturing jobs, how would
you explain the projection in utility jobs going down?
Mr. Hall. You mean what is behind the----
Mr. Tiahrt. Yes, what is behind the projection? Is it
because we have higher productivity in generating power or
electricity or other forms of energy?
Mr. Hall. To be honest, I do not know great detail on that
one specifically. A lot of what we do, obviously, is we look at
trends in employment within the industry. I am not sure----
Mr. Tiahrt. It makes the assumption that utilities are in a
more productivity trend, higher productivity trend than we
would see, and we expect that to continue.
Mr. Hall. I believe that is so. That is certainly the case
with manufacturing. That is part of why we talk about
manufacturing jobs declining over time.
Ms. Fitzgerald. I can speak to the utility question a
little bit.
Mr. Tiahrt. Please.
Ms. Fitzgerald. I am working on a book on green jobs and
career advancement right now.
Part of it is, when you talk about wind or solar, the
utilities are purchasers of that power, so that the jobs
associated with wind or solar will not be credited under
utilities, since they are simply purchasing it.
Mr. Tiahrt. I see. I got something from my power company
here in Northern Virginia, Dominion. It is customer connection.
It is sign up for green power. In red--and perhaps there is
some analogy of this--it says purchase power equal to 100
percent of your monthly electrical usage. The cost is an
additional $0.105 per kilowatt hour. For example, if you use
1,000 kilowatts, that is $15 more. You could also purchase
blocks at 133 kilowatts at $2, which calculates basically the
same cost, $0.105 more kilowatt hour.
Apparently, it is more expensive to generate green
electricity. I am a little positive because electrons are not
colored. What little I know about electrons, they are not
colored. But it does cost more to generate green power at this
point.
Ms. Fitzgerald. Let me just give you an example. One is
Austin Energy. Austin Energy is a utility in the Austin, Texas
area where there is a mandate from the city, a portfolio
standard to produce a certain percentage of their electricity
from renewable sources. They just signed on to produce a 300
megawatt solar farm that is going to be built. They will
purchase that power. They got a fabulous deal, it is about
$0.17 a kilowatt. Natural gas is about $0.08 or $0.09. So what
they are doing----
Mr. Tiahrt. Retail or wholesale?
Ms. Fitzgerald. That is their purchase cost. And what they
are doing is investing in renewable energy in the belief that
the cost will go down over time, and there is every reason to
believe that; it already has become par in wind. But as much
solar as they move to thermal solar and thin film solar, much
more likely to move in that direction. So it is more expensive.
So a plan like you mentioned, that Austin has, it is either
because you have a very green community and they sign on. But
what you are finding is a lot of manufacturers are actually
signing on to those green power purchase plans because they are
long-term plans. So they will go to X wind farm and say we are
going to purchase all your energy over the next 30 years. Then
they will lock people in to that price. So that is very
appealing as a business to know what that utility cost is going
to be over the long term.
So you either get green people who are willing to pay the
premium for the renewable energy or you get your big customers,
your manufacturing and other institutional customers who like
the security of the long-term prices. And sometimes with wind
it is actually cheaper over the long run.
Mr. Tiahrt. What I have seen in Kansas, Fort Hays State
University, for example, their power rates are determined by
the high usage months, which are August and September because
of air conditioning. That is when the students come. So they
have bought diesel-powered generators and are what they call
cost shaving. When they get to a certain usage, these
generators kick on and that holds their rates down for the rest
of the year.
Ms. Fitzgerald. But that is one way they can deal with
this. Another way they could deal with that would be some of
the efficiency programs and encourage the universities and
others to go to much more efficient systems of air conditioning
to shave that peak; and that is what Austin Energy does as
well.
Mr. Tiahrt. I guess we will have time later on for another
round?
Mr. Obey. Well, until 1:00.
Mr. Tiahrt. Until 1:00? Okay, well, I think I will yield
back.
Mr. Obey. Mr. Honda.
Mr. Honda. Thank you, Mr. Chairman.
To Dr. Fitzgerald, just a quick question. It is a training
question. Are there small changes that we can make this year to
Title 8 training programs to expand opportunities to the CNAs
and LPNs without creating new programs? If you would like to
look at that and get back to us, we would appreciate it.
Ms. Fitzgerald. Okay.
Mr. Honda. A general question. We are all looking at the
green collar workforce and we are all involved in certain kinds
of activities, but on an international level, when we are
looking at global activities, and with the current distrust
between our Country and China for historical reasons, but also
the relationship that we have because of trade and things like
that, are there opportunities for the areas that we have
influence over to create what might be called a sister city
kind of relationship of activities here and linked with another
group in China so that we can start looking at ways to find
commonality so that we can start, one, develop confidence with
each other, a track record?
And I do not think it needs to be formalized through State
Department or anything else like that, but kind of a people-to-
people like activities to like activities to start moving this
ball towards some international cooperation so that at a
certain point in the future, as a Country, we will be ready and
have a little bit more work done with people when we are ready
to look at a relationship between our Country and China and
ways to move forward on this struggle to attack this global
warming thing, the greenhouse gases kind of challenge that we
have in the future?
Ms. Fitzgerald. Is that for me?
Mr. Honda. Anyone.
Ms. Ellis-Lamkins. It can be for anyone.
Ms. Fitzgerald. You want to go first?
Ms. Ellis-Lamkins. Go ahead.
Ms. Fitzgerald. There are a lot of sister city programs,
and I do not know that they are very meaningful.
Mr. Honda. Well, what I was thinking of, the model would be
something like that, where you find likes in the other country
so you can start developing this relationship and build trust
and things like that.
Ms. Fitzgerald. Well, in terms on the green issues--and you
may want to speak to this--there is an international
organization called ICLEA. I never remember what it stands for,
but it is an organization working on climate change and
sustainability issues in cities that offers technical
assistance, primarily working in Europe, South America, and the
United States. And it would be very interesting, particularly
because they are building brand new ecocities in China to try
to bring Chinese cities into that organization. So I think
around the global warming or sustainability issue in cities
where there is an organization that probably would be very good
in facilitating that.
Mr. Honda. Are we involved in ecocities also?
Ms. Fitzgerald. Are we involved in ICLEA? It is city-by-
city. There are about 850 cities throughout the world that are
involved in that, and many area. Is Oakland?
Ms. Ellis-Lamkins. I do not know that Oakland is, but San
Jose is.
Mr. Honda. Okay.
Ms. Fitzgerald. I think the real issue with these--I am
actually doing some research on these various organizations.
Seven hundred some U.S. cities have signed on to the U.S.
Council of Mayors Climate Change Agreement, and so what? It
does not require them to anything, so what we really need to
focus on are organizations on the ground that are working in
cities so that these umbrella organizations are meaningful in
terms of motivating change.
Mr. Honda. Well, the question was taking on that activity
and finding a like, for lack of a better word, a kindred spirit
in China that you can link up to and create this partnership so
that people start it before government starts.
Ms. Ellis-Lamkins. Mr. Honda, I think it is an excellent
question because I think the real challenge is how do you
create a spirit of cooperation among people who want change.
And I think there are a lot of groups in China who are also
doing like was talked about before, who are trying to do work
both around global climate change and also trying to create
models. I think there has also been a lot of government
investment, certainly, and infrastructure and technology. So I
think we both can learn from where investments were made, how
to make it easier to be essentially entrepreneurial in spirit.
And in addition is to figure out what are the groups that
we can partner with. And we would certainly be happy to send
your office a list of groups that we think might be prospective
partners in China and also to think about groups on the ground
that are doing work here in the United States that are in some
of those international relationships.
Mr. Honda. Great. Thank you.
Mr. Obey. Dr. Hall, you said that four States right now are
at 10 percent or above in terms of unemployment. Which ones are
they?
Mr. Hall. They are Michigan, 11.6 percent; South Carolina,
10.4 percent; Rhode Island, 10.3 percent, and California, 10.1
percent.
Mr. Obey. South Carolina, you say, is among them?
Mr. Hall. Yes.
Mr. Obey. Okay. And which are the next tier? Which States
do you expect that we will see above 10 percent within the next
three months or so?
Mr. Hall. It is difficult for me to project data, since we
produce the data. It always sort of puts me into a bind because
we do collect the data. I can tell you that the trends for all
the States up to now have had rising unemployment rates and
there has not been pretty significantly rising unemployment
rates; all 50 States have risen since the recession started,
and there is no real indication yet that that is going to stop.
Mr. Obey. What would you say are the characteristics of the
four or five States that, at this point, have the lowest
unemployment levels?
Mr. Hall. It is hard to say because the States seem to have
almost characteristic unemployment rates. Some States run
generally above average, some run generally below average. I am
sure a lot of it has to do with their industry mix, what sort
of industries they have got. There has been such a long-run
trend, for example, in manufacturing, declining employment in
manufacturing. States who heavily invest in manufacturing have
generally higher unemployment rates, for example. All the
States have gone up because the unemployment has gone up in all
industries, just about. So it has been very, very widespread.
It is just that some States started from higher levels.
Mr. Obey. The Brookings Institution recently released a
report on middle-skilled jobs which they say constitute nearly
half of the U.S. employment, and the report defines these jobs
as those that require significant amount of education and
training, such as an Associate degree or certificate, but not
necessarily a four year Bachelor's degree; jobs like plumbers,
machinists, etc. The report seems to support the notion that
there are good paying jobs that do not require a significant
post-secondary education, or at least not four years.
What is your reaction to the notion of middle-skilled jobs,
whether there is a skill that needs to be addressed today and
whether the coming retirement boom will widen the skills gap?
Mr. Hall. That is a good question. Obviously, our
projections show job growth at all skill levels, but there are
sort of two spots where it really jumps out. I have got a nice
chart I can look at here. One is at the very lowest level, a
lot of replacement jobs at sort of minimal training level jobs.
And then there is a lot of job growth at college education,
Bachelor's degree or above. So that does leave a fairly
substantial gap in between where the job growth is not likely
to be quite as high.
Mr. Obey. One other question for you. How much does the
decline of manufacturing in this Country, in your judgment, add
to the gap between incomes in this Country? Do you have any way
of assessing that?
Mr. Hall. Not really directly. That is a good question,
though, because I think you are right. I think the
manufacturing jobs probably do have their share of those in
between education levels that you are talking about, those in
between jobs, something below a Bachelor's degree and something
above minimal training. So I have not studied it, but my guess
is that that does contribute.
Mr. Fitzgerald. May I respond to that one? Because I think
there is plenty of evidence to show that the decline of
manufacturing has contributed to the widening income gap in the
United States, and that is why a lot of the green jobs work is
so important, because so many of these jobs are in
manufacturing. And the representative from Ohio earlier spoke
about the businesses in Ohio that could produce parts for the
wind turbines. There is a whole organization in Ohio that is
trying to make that happen, make the supply chains in
manufacturing for wind, for other forms of renewable energy;
and time after time, what the manufacturers are saying is we
cannot get people that are willing to go into these jobs, these
training programs, certificate level or whatever.
So supporting policy in the green area that would support
manufacturing has a potential for creating a lot of those
middle wage jobs and also the health care. I did not get a
chance to talk about it, but those allied health technician
positions, most of them are either 9-month to 1-year community
college programs, and they pay living wages.
Mr. Obey. Let me ask either one of you. Let me take the
devil's advocate position. There are some people around here
and some people around the Country who will pooh-pooh the whole
idea of green jobs and they will say that is just the latest
fad, that is just the latest label; people are going to shop
around this Country and this budget, looking for anything that
is labeled green. They will try to associate themselves with it
and pull off a piece of the change.
What is your response to that? What would you say to
demonstrate that when you are talking about developing green
jobs in the economy, that you are taking a hard-headed look at
economic realities and not just behaving like you are permanent
president of an optimist club or something?
Ms. Ellis-Lamkins. Thank you for the question. First, let
me apologize for being late; I misunderstood.
Mr. Obey. No, we got back earlier than we thought.
Ms. Ellis-Lamkins. Okay.
I think that is a really important question and I think it
is a pretty consistent question when change happens. When new
and exciting change happens, people freak out. It is a pretty
normal response. You know, we sat with a group of CEOs----
Mr. Obey. Never in Congress.
Ms. Ellis-Lamkins. Never in Congress, thank gosh. But we
sat with a group of CEOs in Silicon Valley, and listening to
their stories from Google to Hewlett Packard, to thinking about
when they made the case that there was something different
happening and that technology might transform the way we
worked. People disagreed, thought they were crazy, and thought
it was something that would only happen in California.
So what I would say to people who say it is not real, is I
would say they should look at the examples from solar, where we
are beginning to see not only the installation of solar in
places like Richmond and Atlanta, but they should look at not
only what is being created, but they should think about whether
we want to be on the front of innovation.
If you had said, five years ago, you thought U.S. car
manufacturing could make a resurgence, but when you look at
places like Tesla, one of the only companies that is going to
be increasing the numbers of manufacturing jobs in auto making,
when you look at companies that are thinking about that, when
we have sat with these companies that are ready to grow, we
look at Chicago Republic Windows, the workers that stayed in
the plant, that was bought by someone who was actually going to
use it to do retrofitting as part of the stimulus package.
So what I would say to them is when we look at examples of
manufacturing that used to exist, and what we see is not only
the commitment to grow, but to be able to increase it, those
jobs are going to increase; not just stay where they are, but
increase. So the question is will we be ready as a Country for
it.
Ms. Fitzgerald. Just to add to that, if we just look at
renewable energy, solar and wind, the United States is the
innovator of solar energy, and right now, if we looked at both
in solar and wind, who are the top 10 producers, we would have
maybe one or two companies that are in the United States. We
have just let the manufacturing go. And in wind and solar, 70
to 75 percent of the jobs are in manufacturing. And what are we
talking about? We are talking about projects in the ground.
That is important. But if we are not building them here, we are
not going to take advantage of those jobs, and we really have
to build that in.
Another example is public transportation. We are talking
about expanding subway systems, light rail systems, all of
these creating jobs in construction; zero on producing them
here. Because there are domestic content, we do a little bit of
the assembly. So like we get maybe 10 percent of the value
added on this.
So when we are thinking about the stimulus package, let us
make sure that we look at how some of these manufacturing jobs
are going to be U.S. jobs; otherwise, we are just going to be
paying for manufacturing jobs elsewhere.
Mr. Obey. Well, to me, one example about which I am the
most zealous is the example of new battery technology for the
auto industry for cars that we would like to see running on
electricity rather than gasoline. I, for the life of me, do not
see how our auto industry recovers international leadership
unless we are in the forefront of developing new technology
that includes new kinds of batteries that will power those new
kinds of vehicles, which is why we put over $2,000,000,000 into
the stimulus package for that purpose.
What policies should we consider to maximize the earnings
potential of the green jobs we are creating, as well as the
policies that keep green jobs at home? Any other specific
suggestions you have on how to build the focus to do that?
Ms. Ellis-Lamkins. I have a couple. You know, I think that
there are a couple things that really are important. The one
thing that I want to just raise that we hear time and time
again in local communities where they are doing excellent work
is their concern about Federal preemption when they have good
local law. So one thing is what do you think when there are
good local standards that are stronger than the Federal
regulation? So I would first just raise the issue of figuring
out how to recognize good standards at a local level.
The second is there are a lot of good models for this, from
community benefits agreements to project labor agreements. The
way we have often thought about it is that there is a three-
pronged approach: pre-qualification of contractors, standards
when there are contracts in place, and enforcement and
resources for enforcement. So part of it is also making sure,
when there is an investment, there is a way to ensure that the
regulations are actually maintained.
In addition, we have got a proposal for the Clean Energy
Corps to think about how do you create those jobs, encourage
workforce development with that, and to be able to make sure
that is funded.
In addition, funding the Green Jobs Act I think will be
critically important in the future. Thinking about
manufacturing, many cities and jurisdictions across the Country
are putting aside millions of square feet to be able to attract
manufacturing industrial land and to think about what that
strategy will be so that there is a package to be able to make
sure that manufacturing happens and that it happens with
standards.
I think you made a great point, Chairman Obey, about even
the idea of middle class jobs. We have 48,000 apprentices in
this Country just alone in the plumbers and pipefitters, and
for us to think about how do we make it easier for folks to be
able to join those types of programs and how do we ensure that,
when there is investment spent through the recovery money, that
those jobs are jobs that will continue, not short-term jobs. So
thinking about pre-apprenticeship opportunities so that people
move into those jobs.
Mr. Obey. Dr. Fitzgerald, with respect to health care, you
were talking earlier about the need to try to increase wages
for people working in the field, and you mentioned nurses, for
instance. You know, the general concern in this Country is how
we reduce health care costs, so when you talk about increasing
wages in the health care field, that would seem to be
counterintuitive. But you mentioned that, in fact, it could
help save money or increase quality because of lessening of
turnover.
Beyond the turnover issue, how else would you defend the
idea that we can afford to provide universal health care with
rising wages at the same time that the President is talking
about reducing health care costs by health care reform?
Ms. Fitzgerald. Well, first, of course, there is the
turnover issue, but there is also the broader level of
commitment to employment. So Kaiser Permanente, for example, in
the programs they have developed throughout the Country with
their 27 unions, one of the things they have really done is
return on investment analysis that definitely shows that by
investing in your workers and creating opportunities for them
to advance lowers costs dramatically in that, for example, to
replace a nurse costs about $150,000 in the whole time spent
when that position is vacant than when it is filled with
someone that needs to learn a whole new system.
So that is one aspect of it.
I think another aspect of it is quality of care. If you
have invested in a better trained aide, they are more likely to
help reduce, for example, falls, which is a major problem; bed
sores, urinary tract infections because people are not taken to
the bathroom enough. So that better trained aides and licensed
practical nurses deliver better care and actually reduce the
health care costs of those facilities that invest in them.
So that is another key area.
And the other is a morale issue so that if people feel
invested in and part of the organization, they are part of the
process and can help an organization look for ways to cut
costs, and nursing homes, it is in the book, can demonstrate
that that is the case.
So I would say those are the three key areas.
Mr. Obey. One last question. Can you elaborate on how much
of the nursing shortage and limited nursing career ladder
opportunities are due to nursing school faculty shortages? I
keep hearing that even if we provide funding for nurses
training, we have a bottleneck because often people who are out
in the field are making more than people who are on the faculty
trying to teach people to be nurses.
How do you see us dealing with that problem?
Ms. Fitzgerald. I would look to Oregon in the longer part
of my testimony that talks about different models for making it
easier to do the training, whether it is SIM-Man training to
replace some clinicals, coordinating and so forth. But, I think
the most obvious thing is you raise the wages at the university
level. But it is difficult to do, even for community colleges,
because they are very expensive programs to run in terms of the
faculty-student ratio is much smaller than it is when you can
put 500 students in a history class. And throughout the
curriculum you have that kind of student-teacher ratio. Plus,
there are the clinicals. There is a real shortage of clinical
sites. So what you find is a hospital is much more likely to
accept clinicals from a Bachelor's degree program than it is
from the community college, so you create that bottleneck.
So it has to be dealt with in terms of technological
creativity and how we educate nurses. But it just makes perfect
sense; no rational nurse is going to make the decision I am
going to teach for $20,000 less a year and put in more hours
than I would. So I think that kind of legislation that helps
the universities subsidize those salaries would be one way to
address that bottleneck.
Mr. Obey. Well, another would simply be if we had State
legislators who were willing to meet their responsibilities to
their own universities. I know that in my State, when I left
the legislature, about 42 percent of the operating cost of the
University of Wisconsin was paid for out of the State General
Fund financed by the State legislatures. Today, that is down to
about 19 percent. They have walked away from their
responsibilities to fund the universities at an adequate level.
Then they wonder why tuition goes up and it becomes less
affordable for kids to go.
Ms. Fitzgerald. Right. That is exactly right.
Mr. Obey. Mr. Tiahrt.
Mr. Tiahrt. Mr. Chairman, I just want to thank you for a
good hearing. I thought it was very interesting, stimulating,
and I think we learned a lot. So thank you very much.
And thank you to the witnesses. Appreciate your being here.
Mr. Obey. Thank you.
Thank you all. Appreciate it. Thanks for coming.
Thursday, March 26, 2009.
NATIONAL INSTITUTES OF HEALTH: BUDGET OVERVIEW/IMPLEMENTATION OF THE
ARRA/STATUS OF NATIONAL CHILDREN'S STUDY
WITNESSES
RAYNARD KINGTON, M.D., PH.D., ACTING DIRECTOR OF THE NATIONAL
INSTITUTES OF HEALTH
JOHN NIEDERHUBER, M.D., DIRECTOR, NATIONAL CANCER INSTITUTE
STORY LANDIS, PH.D., NATIONAL INSTITUTE OF NEUROLOGICAL DISORDERS AND
STROKE
ANTHONY FAUCI, M.D., DIRECTOR, NATIONAL INSTITUTE OF ALLERGY AND
INFECTIOUS DISEASES
DUANE ALEXANDER, M.D., DIRECTOR, EUNICE KENNEDY SHRIVER NATIONAL
INSTITUTE OF CHILD HEALTH AND HUMAN DEVELOPMENT
GRIFFIN P. RODGERS, M.D., DIRECTOR, NATIONAL INSTITUTE OF DIABETES AND
DIGESTIVE AND KIDNEY DISEASES
PATRICIA GRADY, PH.D., R.N., F.A.A.N., DIRECTOR, NATIONAL INSTITUTE OF
NURSING RESEARCH
JOSEPHINE BRIGGS, M.D., DIRECTOR, NATIONAL CENTER FOR COMPLEMENTARY AND
ALTERNATIVE MEDICINE
JOHN RUFFIN, PH.D., DIRECTOR, NATIONAL CENTER ON MINORITY HEALTH AND
HEALTH DISPARITIES
LAWRENCE TABAK, D.D.S, PH.D., ACTING NIH PRINCIPAL DEPUTY DIRECTOR AND
DIRECTOR, NATIONAL INSTITUTE OF DENTAL AND CRANIOFACIAL RESEARCH
Mr. Jackson. I would like to welcome Dr. Kington and the
institute and center directors who are seated behind him.
At today's hearing, we would like to discuss NIH's
implementation of the Recovery Act funding NIH received, the
President's fiscal year 2010 budget for NIH to the extent that
it has been made public and the status of the longitudinal
National Children's Study which many of our Subcommittee
members are interested in but which has never received much
discussion because President Bush tried his hardest to
eliminate it.
Between the omnibus spending bill and the Recovery Act, we
were able to provide an $11.3 billion increase for NIH, the
largest ever 1-year funding increase to NIH.
I am sure, Dr. Kington, that were Dr. Zerhouni here today
he would love to be in your seat these days.
With that kind of increase, the Committee will be watching
carefully to be sure that NIH spends it in a way that both
stimulate good science to propel our economy and to create
high-paying jobs throughout the Country.
We appreciate having some of the NIH institute directors in
the front row today. Dr. Kington, you should feel free to have
them respond to specific questions if you would like. There is
an empty seat to your right, to my left, with a mic for that
purpose.
Mr. Tiahrt, are there any comments that you would like to
make?
Mr. Tiahrt. Thank you, Mr. Chairman.
I would like to welcome Dr. Kington as well and the
National Institutes of Health center directors who are here.
Thank you all for coming.
Mr. Chairman, I am particularly glad you scheduled this
hearing, given that NIH currently has 33 percent more resources
than it did last year. I am interested to know how it is going
to be spent.
While I would like to discuss the upcoming budget, it
appears that our friends in the Executive Branch may,
themselves, not yet know what it contains. That is unfortunate
because I know that the Chairman and I both would like to get
started in earnest, so we can avoid the end of year crunch that
leads to an omnibus bill.
I am always pleased that we are going to be discussing the
National Children's Study and some of the problems it has
encountered over the last couple of years--problems that, in my
view, should never have happened and have jeopardized the
entire study.
At any rate, I look forward to the testimony, and I yield
back.
Dr. Kington's Oral Statement
Mr. Jackson. Thank you, Mr. Tiahrt.
Dr. Kington, we have your written statement. Please feel
free to summarize with oral remarks so that you will have
adequate time to answer any questions.
We welcome you to the Committee and congratulate you for
your ascendancy in this acting role.
Dr. Kington. Thank you, Congressman Jackson, and good
morning to you and other distinguished members of the
Subcommittee. It is an honor and a privilege to appear before
you today to discuss the National Institutes of Health's
implementation of the American Recovery and Reinvestment Act.
Before I begin, I would like to introduce my NIH colleagues
who have joined me: Dr. Anthony Fauci, Director of the
Institute of Allergy and Infectious Diseases; Dr. Duane
Alexander, Director of the Eunice Kennedy Shriver National
Institute of Child Health and Human Development; Dr. Josephine
Briggs, who is the Director of the National Center for
Complementary and Alternative Medicine; Dr. Patricia Grady,
Director of the National Institute of Nursing Research; Dr.
Story Landis, Director of the National Institute of
Neurological Diseases and Stroke; Dr. John Niederhuber,
Director of the National Cancer Institute; Dr. Griffin Rodgers,
Director of the National Institute of Diabetes and Digestive
and Kidney Diseases; Dr. John Ruffin, Director of the National
Center on Minority Health and Health Disparities; and Dr.
Lawrence Tabak, Acting NIH Principal Deputy Director and
Director of the National Institute of Dental and Craniofacial
Research.
First, I want to express my sincere gratitude on behalf of
the Agency for your support of NIH in the fiscal year 2009
budget and for the continued trust you place in NIH to make the
discoveries that will lead to better health for everyone as
reflected in the recent appropriation of the $10.4 billion in
ARRA and the 3.2 percent increase in the Fiscal Year 2009
Appropriations Act.
I thank you on behalf of the many scientists we are able to
support at more than 3,000 research institutions throughout the
50 States and U.S. territories and on behalf of the public who
count on our research to help detect, treat and prevent
hundreds of diseases and conditions.
As you noted, I submitted my testimony for the record, and
I will try to just highlight key points for you this morning.
As we are all painfully aware, every sector of America is
facing challenging times from the drastic downturn in the
economy. The biomedical research community has not been spared
from this turn of events. It is an unfortunate irony, however,
that it comes at the same time that we are seeing extraordinary
scientific opportunities for improving health.
This is worrisome not only because it means fewer jobs but
also because innovation and a constant influx of new talent are
crucial to the Nation's economic success and to a robust
biomedical research enterprise. So it is timely that the
President and Congress provided ARRA funds to NIH to stimulate
the economy and to advance biomedical and behavioral research.
To bring the impact of ARRA down to the individual level, I
would like to share with you the following. One of our program
directors received an email several days ago in response to
news that an applicant's grant application is being considered
for funding with ARRA money. Here is an excerpt from the email:
``We gave a termination letter last Friday to my longtime
post-doc. His job has been saved. He is going to be thrilled to
hear about his change of fortune. I would also like to hire a
technician with the new funds since I presently don't have
one.''
I am certain that similar scenarios will occur throughout
the Country over the next two years as we implement the Act.
Your decision sends a strong signal to scientists in the
field and to bright young people who may be one day choosing
science as a career, that the United States is willing to
support outstanding research and outstanding scientists.
Here is only a sampling of the important work that we will
support with ARRA funds. For example, we will expand rapidly
our understanding of a wide range of diseases and conditions
including diabetes, forms of cancer, addiction, glaucoma, heart
and lung disease, arthritis, kidney disease and mental
disorders. In addition, we will expand our efforts in
community-based research with a special focus on minority and
under-served populations and make further investments in the
potential applications of nanotechnology.
Just to briefly review, the ARRA provided NIH funding in
the following ways:
It appropriated $8.2 billion to NIH for scientific
research.
It allocated $1.3 billion for construction and equipment at
our grantee institutions, $1,000,000,000 of that focused on
extramural construction and renovation and $300,000,000 to
shared instrumentation and large capital research equipment.
The remaining $500 million will be used to fund high
priority repairs, improvements and construction on the NIH
campus to enable the highest quality of research to be
conducted.
In addition, $400 million was transferred to NIH from the
Agency for Healthcare Research and Quality to support research
in comparative effectiveness.
Let me review how NIH will be using the dollars in direct
support of science.
NIH is using a nimble approach to investing the money
quickly, with the greatest impact. For example, we are in the
process of determining which of the highly meritorious
applications that we were not able to fund last year would make
sense scientifically to fund for the next two years with ARRA
dollars.
NIH has already issued a number of new funding
announcements. In particular, we have made targeted grants
announcements to stimulate research in high priority areas. An
excellent example is our announcement this week of four
research grant announcements related to autism, a disease that
affects so many families in America.
NIH has committed $60 million of research funding to
address the differences across the autism spectrum of
disorders. Researchers will help develop and test diagnostic
screening tools, assess risk from exposures and test early
interventions and adapt existing pediatric interventions for
this population.
NIH has created a number of new programs that will spur new
areas of research and trigger an almost immediate influx of
research dollars into communities across the Country. For
example, we have introduced the Challenge Grants Program, the
Grand Opportunity Program or GO Grants, Signature Initiatives
and a program to encourage the recruitment of new faculty to
conduct research and, finally, a summer program to hire
students and science teachers in research laboratories, and I
will speak a little bit about a number of these programs next.
For the Challenge Grants, we issued the largest RFA in the
history of NIH. This is a shortened version of it, a 220-page
document that lists 237 scientific topics in 15 broad
scientific areas. We expect to devote at least $200 million to
this effort.
The research funded under the Challenge Grants program will
fund a number of important topics including advances in
biosensors, new approaches to HIV therapy, new research in
bioethics, research on health disparities and clinical
research, pain management and the new area of so-called
theranostics, a combination of the words, therapy and
diagnostics, which refers to materials that can both diagnose a
condition and treat a condition--so a material that might be
painted on a tooth that could both detect a fracture and repair
it.
Another new program is the Grand Opportunity Program or the
GO Grants. This program will highlight large-scale research
projects that accelerate critical breakthroughs, early and
applied research on cutting-edge technologies and new
approaches to improve interactions among multidisciplinary and
interdisciplinary research teams.
NIH is supporting a number of important Signature
Initiatives that will support exceptionally creative and
innovative projects and programs to address major challenges in
biomedical research. The initiatives will cover new scientific
opportunities in nanotechnology, for example, genome-wide
association studies, Alzheimer's disease, oral fluids as
biomarkers and community-based research just to name a few of
the potential topics.
We have also announced an important new program to support
newly trained faculty to conduct research. This will help
address the need to support early career scientists who are one
of NIH's top priorities. Funding will be provided to hire and
provide appropriate start-up packages and to develop pilot
research projects for newly independent investigators.
We are also particularly delighted to tell you about our
expanded summer program for teachers and students across
America. Funds will support short-term summer jobs for high
school and undergraduate students as well as elementary,
middle, high school and community college science educators in
laboratories across the Country and will provide several
thousand young people with an opportunity to experience the
world of research, and we hope this experience will spark their
desire to become scientists.
We are mindful that a top priority for the use of ARRA
funds by NIH is to create and preserve jobs as well as
increasing purchasing power in all corners of the Country. We
firmly believe that we can do this while carrying out the core
NIH mission and without compromising our commitment to fund the
best scientific research ideas.
We will fulfill ARRA's comprehensive reporting requirements
including jobs created and preserved, tracking of all projects
and activities and trend analyses. To track all of NIH ARRA-
related activities, I invite you to go to our web site,
www.nih.gov, which we will update regularly.
In summary, groundbreaking discoveries are most often built
on the foundation of many incremental advances that bring us
closer to diagnosis, treatments and other public health
improvements expected by Congress and the American people.
Because of ARRA funds, there will be more discoveries
across the Country next year and many years to come. These
findings will yield better understanding of the major diseases
and disorders including those that I touched upon here today
and hundred more as well as providing keys to allow all of us
to live healthier lives.
As I said in my opening comments, we are grateful for your
commitment to biomedical research and all the promise that it
brings to people here in the United States and around the
world.
We have employed a number of innovative strategies to
quickly and wisely invest ARRA funds. We will stimulate the
economy, we will create jobs, and we will advance science. Most
importantly, ARRA will help us contribute to our principal
mission which is to make scientific discoveries that will
improve the public's health.
I would be pleased to answer any questions, and I will take
advantage of the opportunity to call upon my colleagues for a
special response to particular topics in their areas of domain.
Thank you again.
[The information follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
NIH RESEARCH FACILITIES CONSTRUCTION MODERNIZATION
Mr. Jackson. Dr. Kington, thank you very much for your
testimony.
We are going to try today to adhere as closely as possible
to the five-minute rule. I am going to certainly apply it to
myself.
I want to thank my colleagues for coming to today's
hearing. Chairman Obey, who would normally be chairing the
Committee, has found himself in another conflicting scheduling
event and expresses his deep regrets for not being here to all
of the institute directors, center directors and to you.
The Recovery Bill provided about $1.5 billion for
extramural research facilities and NIH campus research
facilities. Whether the money is awarded for new construction
or renovation, it is sure to generate needed jobs across the
Country. What is your estimate of jobs created through this
funding?
How critical is it to modernize biomedical research
facilities in order to achieve the scientific advances of NIH
that have been outlined in the road map?
And, what is the estimated backlog of creating adequate
research space?
That is my first series of questions.
Dr. Kington. First of all, we anticipate that extramural
construction support, which is the $1 billion that will go out
across the Country, will allow us to deal with extraordinary
backlog on academic campuses throughout the Country in basic
renovation and improvements. I believe the estimate was around
$9 billion of backlog across campuses across the Country, and
this $1 billion is a significant down payment on that large
amount of resources that are needed to bring these buildings up
to speed. We think that it will have a direct impact on the
quality of the research that we support.
And the relatively small amount, the $500 million that will
go to support construction on campus, will also allow us to
substantially improve the quality of our research buildings and
to catch up with the deferred maintenance backlog that we have
accumulated.
We have not estimated exact numbers of jobs that will come
from the construction dollars, but we can get back to you with
estimates. We don't have exact numbers right now.
We have better estimates for the jobs that will come from
the research dollars.
JOB ESTIMATES FROM CONSTRUCTION FUNDS
Mr. Jackson. Can you give us some sense of that?
Dr. Kington. We estimate that each of our grants, on
average, supports between six and seven jobs either in part or
in full. We are in the process of actually doing an even more
detailed study to look at the exact numbers that will come from
the various mechanisms. That comes from a number of studies
that we have conducted by pulling a sample of our grants and
looking at their funding patterns.
One of the opportunities with the reporting that will come
from this, associated with ARRA, is we will probably have
better information than we ever have had about the economic
impact of the dollars that we support.
[The information follows:]
Construction Jobs Created With $1.5 Billion
Dr. Kington: The estimate number of jobs created or maintained by
the $1.0 billion for extramural construction and $500 million to
support construction on NIH owned buildings and facilities is an
approximation. The exact number will depend on the mix of projects,
location, and cost of materials.
The job projection for both the extramural and NIH campus
construction projects is based on an industrial labor conversion factor
of about 5.5 work years per $1.0 million spent. It is estimated about
8,000 work years can be supported with a total of $1.5 billion of
construction funds. If you extrapolate that each work year is equal to
one position then it can be inferred the $1.5 billion will support
8,000 positions.
Mr. Jackson. Dr. Kington, I want to congratulate NIH for a
well thought-out plan and for obligating the unprecedented
funding increase for fiscal funding for NIH. It provides an
unprecedented funding increase for this year and next year,
temporarily hiking the number of new grants and success rates,
but the prosperity is short-lived. After two years of funding,
NIH is back to where it started--low success rates and
potentially scant money for new grants.
That is unless the Administration and Congress acknowledge
the hole we have dug for NIH and own up to our responsibility
to continue stable funding.
I know you would have to be a loyal Administration witness,
but can you give us a straightforward assessment of what will
happen to NIH scientists in 2011 after the Recovery Act money
dries up? How many additional scientists will receive research
support under the Recovery Act and how will those scientists be
supported once the funding dries up?
Dr. Kington. First of all, we have some experience with
planning for large influxes in support to our budget, having
lived through the doubling and then the not so soft landing
that came after the doubling, and we have learned from that
experience.
We are much better at estimating the churn of dollars, and
with these dollars we have made an effort to limit the impact
by limiting our commitments to only the two years of the
dollars that come with the Recovery Act. We, however,
anticipate that if these dollars actually generate the research
advances that we hope they will generate, we will probably have
an increase in applications beginning in 2011.
We have done some estimations, and we believe that it may
drop the success at least several points below what it has been
if we don't have a substantial increase in our budget.
We tried to use these funds wisely, so we can minimize the
out-year impacts. But it is inevitable that if the dollars are
used successfully, we will generate advances which will, in
turn, generate new applications. We are trying to limit that
impact, but in some ways it is an indication of the success of
the funding to generate new scientific advances.
Mr. Jackson. Mr. Tiahrt.
Mr. Tiahrt. Thank you, Mr. Chairman.
Welcome, Dr. Kington. I don't think there is any question
you guys do wonderful research that has dramatically improved
the lives of Americans, and I want to congratulate you on your
persistence.
There is some concern on my part about this pig going
through the python, if you will, this $10,000,000,000 that is
going to be a 33 percent increase to your budget, but it is
only for a limited time. Our Chairman and Chairman Jackson
here, I think, is right to be concerned about how that is going
to be spent.
And I think probably what justifies that concern is the
National Children's Study where we started in 2000 to do some
good things by tracking 100,000 kids from conception, when life
begins, until the natural progress through life. I think it is
going to reveal some very interesting things.
But it originally started out to be approximately
$3,500,000,000 over a 25-year period, and most of us found that
a good plan. Now I am hearing that that cost may actually
double. Is that about right?
Dr. Kington. Well, we have every plan to bring the cost
down, and I can answer in more detail, but we anticipate that
the total cost will not be double.
THE NATIONAL CHILDREN'S STUDY
Mr. Tiahrt. The reason there is a concern is if you take
this $10,000,000,000 pig going through the python and find out
it is really $20,000,000,000 later on, we could shortchange
ourselves and our future by having to shut down research or
limit it when it could reveal some very profitable things for
the life and well being of Americans.
So I would like to know a little bit better about how that
$3.5 billion was developed and how it expanded. Did we decide
we need to include more children in the study or did we have to
hire more people to conduct it?
Did we, after ignoring Kansas, pick up some additional
States? Nothing subtle there.
Dr. Kington. I am just grateful that we are the python and
not the pig. [Laughter.]
The National Children's study is a study of unprecedented
size and complexity that is designed to answer extraordinarily
important questions about the role of the environment and
particularly in the development of children.
This study began out of a working group that identified the
scientific need, and then planning was initiated. Over the last
five or six years, we have had a number of opportunities to
estimate the cost of the study, but we were estimating a moving
target because it became clear early on that once we generated
a comprehensive sort of wish list of scientific sub-projects
that we wanted in the study, it became clear that we would not
be able to fund all of those research components, which is not
unusual for a large research project.
Mr. Tiahrt. Are you still going through that analysis and
so you may be able to limit the increase in cost?
Dr. Kington. Absolutely. In fact, we received advice from
the National Research Council at the National Academy of
Sciences where we were told, advised to have a pause after a
period of an extensive pilot when we could analyze the results
of the pilot, see what worked, what didn't work, see what the
costs were and then to make adjustments.
Mr. Tiahrt. Is that pilot done at the end of this fiscal
year or when will your pilot project be complete?
Dr. Kington. The pilot project consists of seven vanguard
centers. Two are operational now. Five more will come online
next month. They will have about a year of operation, and we
really need that period of time because the study really is
unprecedented.
It is a population-based study. So we are knocking on
doors, trying to find women who are of childbearing age, who
are likely to become pregnant, follow them through the
pregnancy to the birth of the child and then follow the child
through to age 21.
Mr. Tiahrt. If you are arranging relationships, I have a
couple of gals in my office that would like your help.
[Laughter.]
I am being facetious. I am sorry.
Dr. Kington. I will resist the opportunity to comment on
that one.
What we did know was about maybe three or four years ago we
had an estimate of about $3.1 billion. Internal to the study,
it became clear at some point that that was an underestimate of
the entire package that was being piloted. Now we knew we were
going to scale it down some, but it was an underestimate.
A decision was made not to correct the estimates because
the feeling was we would have to go back and correct again once
we had good information from the pilot study. This was an error
in judgment in my opinion.
We have now corrected that error in judgment. We are re-
estimating costs. We are having a number of steps in the review
of the activity including much greatly increased review from
the Office of the Director.
Mr. Tiahrt. Excuse me. I almost out of time, so I apologize
for interrupting you.
I think you are on the right track by reassessing the
study. In any government program, allowing it to grow beyond
its original intent is a great temptation. So I would encourage
you to keep it within the original scope because you had a
great idea.
Let's complete that idea rather than risk jeopardizing it
by expanding it too big and getting it killed because of the
size.
Thank you, Mr. Chairman.
Mr. Jackson. Thank you, Mr. Tiahrt.
I have been informed that we are expecting a fairly lengthy
series of votes sometime between 12:30 and 1:00. These will be
the first and last votes of the day but, again, potentially
lengthy. And so, I am grateful to members who are honoring the
time.
I thank you once again, Mr. Tiahrt.
Mr. Honda.
HEALTH DISPARITIES AND EQUAL ACCESS BILL
Mr. Honda. Thank you, Mr. Chair.
Welcome, Doctor. Your written testimony is very good, and I
really appreciate its detail and being succinct.
The area I am concerned about is the area that you took a
lot of pain to discuss, and that is the communities of color
and the disparities. Hopefully, in your discussion and your
research and your thinking, Asian American populations are
included in there because I think that is a myth out there,
that the communities don't have any problems.
When we disaggregate the community, you know that there
will be different communities with very serious problems. So,
in part of your work hopefully, that will be some of the
direction.
We had a bill in the last session. I believe it was H.R.
3014. It is the Disparities and Equal Access Bill. Essentially,
what we wanted to do was look at all the gaps in our health
system from research to delivery systems, services at the
clinical level, community level--many of the areas which you
have discussed in your paper here.
I was wondering whether, number one, in the last fiscal
year out of the $30 billion that was allocated for NIH, I
believe it was $2 billion or $3 billion was set aside. Two
billion dollars was set aside to study the disparities, and I
was wondering what kind of work was done as a result of that.
Two, where in your studies was there some matching in the
desire that we provide services based upon our bill, figuring
out whether if you are already doing it, what parts of it, what
parts of the bill are being addressed.
And then, three, in the future, how will you be looking at
that in anticipation of a bill being passed or not being
passed? In the direction, whichever you want to go to, there is
a parallel there, an equal desire.
So I was wondering whether you could comment on those
questions.
Dr. Kington. Thank you for the question. This is an
extraordinarily important area for the Agency and for the
American people.
First, I point out the trends for our expenditures in
health disparities. We, as you noted, estimated that about $2.6
billion of our budget in 2008 was devoted to health disparities
research.
We have defined disparities populations, and we certainly
acknowledge that many Asian sub-populations have extraordinary
health care problems. There is great heterogeneity across
subgroups, and that is a theme that cuts across many projects
of research supported by multiple institutes and centers
including the Minority Center.
Mr. Honda. May I just interrupt for a second?
Dr. Kington. Sure.
Mr. Honda. For purposes of the future, if that would be
articulated, that would be greatly appreciated because I think
once articulated and written down then we know that exists and
we pay attention to it. Thank you.
Dr. Kington. We will articulate it in our strategic plan,
and I can go on to that topic. We are in the process of
starting a second wave of our strategic planning process. It is
led by Dr. Ruffin, and Dr. Ruffin may want to comment.
We try to integrate health disparities research across the
entire Agency. Although the Minority and Health Disparities
Center clearly has the lead, we feel that it is important that
every single institute and center understand that they own part
of this problem.
I see, and I can personally tell you that every single
institute and center director sees it as a priority. It was a
priority under Dr. Zerhouni, and it is also a priority under
our ARRA dollars. You may note that in this large compendium of
topics one of the 15 priority areas was health disparities
research.
We anticipate receiving many important applications and
funding them under ARRA. I think that you will see in our
portfolio we have everything from very basic research all the
way through research on systems and how minority groups and
health disparities populations fare within our health care
systems, and I think that you will continue to see that broad
continuum of research at the Agency.
And, Dr. Ruffin may want to comment as well.
Mr. Honda. Thank you.
Mr. Ruffin. I think that the last iteration of the
strategic plan, as Dr. Kington stated, while it had been slowed
getting through the process because there was a lot of
different stages that it had to go through, I can say that 100
percent of the institutes and centers at NIH did not let that
process of clearance slow them down. Many of those issues and
initiatives that are listed there in that plan have already
been initiated.
I think those of you who may have participated and were
present in December at our summit meeting where there was
somewhere in the neighborhood of about 4,400 people. The
purpose of that summit was to give the ICs--the institutes and
centers--an opportunity to report on where we are with the
various projects that we have going on within the ICs at the
NIH, the institutes and centers.
I think that what was revealed at that summit is the
magnitude of research in all of those areas that you just
mentioned that are now underway.
Mr. Honda. Thank you.
Mr. Jackson. Thank you, Mr. Honda.
By the way, I like the idea that when Dr. Kington invokes
your name if you would just step up to the mic. It saves us a
considerable amount of time, and there may or may not be a
second round. But the distinguished institute heads and
directors have traveled a great distance to participate, and to
the extent to which they can participate, we would be grateful.
Mr. Rehberg.
Mr. Rehberg. Thank you, Mr. Chairman.
Could you expand a little bit more on the 14,000 grant
applications?
One of the problems that I have, and I have maybe been
critical of my own party from time to time, we always say we
want to balance the budget except keep your hands off Homeland
Security and Defense, and that is where you end up with the
$500 toilet seats and $200 hammers. When you are not paying
attention, somebody is going to be padding a budget.
When you have an influx of money like $10,000,000,000 and
all of a sudden you go: Oh, goody, goody, goody. Now we can
just expand what we were doing. These may have been
meritorious. However, they didn't make the cut before. All of a
sudden, they are back on the table again.
Give us some confidence that, one it is going to stimulate
the economy as intended, two, that you are not just going to be
throwing money at new projects that hadn't made the list before
and, three, why not just use the money for an expansion or a
continuation of those that you found to be meritorious in the
first round rather than trying to spend it on let's say two-
year projects and then coming back before the Committee and
saying, well, now you have to have a maintenance of effort
because we have begun these very important projects when,
however, they didn't make the cut before.
Dr. Kington. Very good questions.
First of all, it is important to recognize that those
14,000 applications were reviewed and found to be
scientifically meritorious. We received many more applications
that were not funded. This was the top, right below our funding
level.
But it is also important to recognize that that is in the
context of flat budgets. Over the last six years, the NIH
budget has essentially been flat, and we have lost about 17
percent purchasing power. So there was a great deal of pent-up
demand.
We believe that many of those projects can be funded for
two years, and all of them have been found to be scientifically
of high quality and have been reviewed by our councils. But
that is not the only way that we are using these dollars.
Many institutes and centers are also committing equal
amounts, if not more, to supplement existing grants and
contracts as you suggested. These are projects that are already
ongoing in which we are either accelerating or we are expanding
to address new areas for existing contracts. We released two
solicitations for requests for those supplements, and that will
be a major part of this portfolio
We have three big buckets. One is the funding of grants
that were on the table but were very high quality, and if we
had had funds we would have been perfectly comfortable funding
them because they were of high scientific quality. The second
is supplementing existing grants and contracts through either
an administrative process or a competitive process in which we
solicit requests. And the third is the new grant programs such
as the Challenge Grants and GO awards which are only for two
years.
Mr. Rehberg. And your deadline on that is what?
Dr. Kington. The deadline?
Mr. Rehberg. Of this various process of the spending.
Dr. Kington. We have started. We have released the
supplement requests, announcements for administrative
supplements and competitive supplements. We have released the
Challenge Grants. We hope soon to release the GO Grant
application RFAs.
So we are substantially down the track a bit on this, and I
actually think we have elaborate time tables actually to make
sure that we can get the applications, review them and fund
them beginning in 2009.
We are absolutely confident that we have the infrastructure
and the reserve to, one, fund really good science and, two,
fund it quickly.
JOB ESTIMATES FROM ARRA FUNDS
Mr. Rehberg. What is your number on new jobs created with
your $10 billion?
Dr. Kington. It depends upon the distribution across those
pots. We can give you an estimate. As I said, each grant we
believe supports between six to seven jobs in part or full.
We can get back to you with the exact dollar estimates.
Mr. Rehberg. I want not just exact dollar but exact job.
Dr. Kington. Excuse me. The exact number, yes.
Mr. Rehberg. Because the stimulus was billed as a jobs
creation. It got morphed into a job maintenance somewhere along
the line once they realized that it was going to be very
difficult to create as many jobs as were promised. So I want an
exact number that you anticipate, jobs that will be created
with your $10 billion.
Dr. Kington. We will give that to you, and it is required
under the reporting requirements of the Act.
[The information follows:]
Jobs Created With $10.0 Billion
Dr. Kington: The estimate number of jobs created or maintained by
the $10.0 billion provided to NIH in the Recovery Act is an
approximation; the exact number will depend on the mix of grants or
contracts awarded. The Act provided $8.5 billion for scientific
research and equipment, $1.0 billion for extramural construction and
$500 million to support construction on NIH owned buildings and
facilities.
The traditional NIH scientific grant type is called an R01, for
which a study indicates each award supports 6 to 7 part or full
positions. NIH estimates the $8.5 billion funds will support around
7,000 research project grants and contracts of which, about 4,000
should be R01 type grants. We project these R01's should support 24,000
to 28,000 positions in part or in full across the Nation. NIH does not
have the data available to estimate the job creating impact of the
remaining 3,000 grants and contracts that are not R01's. The job
projection for both the extramural and NIH campus construction projects
is based on an industrial labor conversion factor of about 5.5 work
years per $1.0 million spent. It is estimated about 8,000 work years
can be supported with a total of $1.5 billion of construction funds. If
you extrapolate that each work year is equal to one position then it
can be inferred the $1.5 billion will support 8,000 positions. Although
NIH does not have the data to generate comprehensive estimated job
projections, we will continue to work to develop and provide them.
Mr. Rehberg. I understand that. Thank you.
Mr. Jackson. Thank you, Mr. Rehberg.
Ms. Roybal-Allard.
Ms. Roybal-Allard. The National Children's Study is a study
that is extremely important for communities such as the ones I
represent that are overrun with freeways and every kind of
unwanted project that you can imagine. So, if I may, I would
like to direct my questions to Dr. Alexander who I believe
oversees the studies.
Is Dr. Alexander here?
Dr. Alexander. Yes.
Ms. Roybal-Allard. Okay. Dr. Alexander, first, I would like
a little bit of a clarification of the response to Mr. Tiahrt's
question because I have heard that some concern has been raised
about the many variables that you are piloting in the National
Children's Study. The concern is that it may double the budget
is what I have heard.
Can you explain what the reasons are for so many variables
and do you share that concern in terms of doubling of the
budget?
Dr. Alexander. When we made the decisions to go ahead with
the pilot study that was very broadly encompassing of many of
the ideas, not all, that had been proposed for inclusion in the
study, we did it for several reasons.
First, we felt that the best way to decide what the content
of the final protocol for the main study would be, would be
based on experience in testing in the field of the various
ideas, possibilities of different approaches for recruiting
subjects, different approaches for collecting data, et cetera.
The best way to get that information was to actually test it in
the field.
There was never any anticipation that we would double the
size of the study or even massively increase it. However, the
study itself was conceived as a public-private partnership. So,
in addition to the Federal funds available from the
appropriation, we also anticipated that things that could not
be incorporated into the protocol funded by the appropriation
might be picked up by other interested parties, other
components of the government, other government agencies, the
private sector, industry, foundations, advocacy groups,
whatever.
We wanted to have an identification of things that were
useful to do but did not make the cut, if you will, of
inclusion within the protocol within the financial constraints
that there would be, and we would hope many of these other
things might be picked up by these other sources.
Therefore, it was advantageous, in addition to trying to
pick the best things for the final protocol, to include more
things so that we might be able to offer these up to expand the
reach of the study and really fulfill its purpose much more
extensively than just the appropriated dollars would be able to
do alone.
Ms. Roybal-Allard. Also, many parents have concerns about
enrolling their children in clinical studies, and this is
particularly true of ethnic and minority groups who could
benefit greatly from this study.
Could you please tell the Committee what is being done to
recruit and to retain racially ethnic and culturally diverse
children and what your contingency plan is to support study
sites that do not achieve the targeted minority enrollment
rates that you are anticipating?
Dr. Alexander. Yes, those are very important issues that
the study has tried to address from the beginning. First of
all, the study itself is one that looks like America. We have
rejected the approach, based on the best scientific advice we
could get, of a convenience-based sample in favor of a
nationally representative sample so that the children included
will come from an appropriate proportional representation of
their representation in the population.
There will be representation from all racial and ethnic
groups, socioeconomic status groups, geographic distribution,
et cetera.
Ms. Roybal-Allard. Doctor, I am sorry to interrupt, but my
question really is what kind of outreach are you going to have
in order to assure that you get the diversity that you are
seeking?
Dr. Alexander. Okay. Very good. Let me get to that.
That then has been also an effort we have made from the
beginning. The outreach includes presentations to organizations
that represent minorities across the spectrum--Hispanic
organizations, African American organizations, whatever. We
have presented several times to the National Medical
Association and have their endorsement and so forth.
We have also charged each of the sites with a broad effort
in community outreach. Each of them has a person on their staff
directed toward community outreach and reaching people in the
community, both directly as well as through the media, through
their community leaders and organizations and so forth. So that
is being done.
In addition, we have publicity that has preceded our entry
into the field in the sites where the study is being done.
We also have efforts underway to be sure that if we have
difficulties in the field we are able to deal with them. We
have sensitivity training being done for all the people who are
doing the interviewing.
And, our oversight center will be looking at our minority
recruitment efforts to be sure that we are making our goals. If
we are not, then we are prepared to step in and increase the
efforts in the sites or to increase efforts at supplementing by
over-sampling in other areas.
Ms. Roybal-Allard. Doctor, I am just hoping that there will
also be forms and applications and presentations in appropriate
languages and that the research teams themselves will be
culturally and linguistically competent.
Dr. Alexander. They are. In fact, virtually all of the
documents for the public are in English and Spanish, and we
have seven different languages for the consent process.
Ms. Roybal-Allard. Thank you.
Mr. Jackson. Let me just indicate also that I have just
received an update that the votes are likely to come now, the
final votes of the day, between 11:30 and noon. So the extent
to which we have questions of Dr. Kington and the extent to
which we have questions for institute heads or directors,
please feel free to incorporate them now as the first round
might be in fact our only round.
Mr. Ryan.
Mr. Ryan. You are running a very tight ship, Mr. Chairman.
Mr. Jackson. It is all we have.
Mr. Ryan. It is all we have. That is right. [Laughter.]
Thank you very much.
I have had the opportunity over the past couple of months
to get involved in some different programs that are going on
around the Country.
I went out to the University of Wisconsin at Madison and
met with Dr. Richard Davidson out there who is doing a
significant amount of brain research. One of the issues that he
is trying to deal with and I think a lot of people around the
Country are trying to deal with, whether it is in the field of
health care or in the field of education, is how our society at
this point in time is dealing with stress and the ripple effect
that stress has throughout our communities, throughout our
health care system, throughout our education system.
So I have a couple of questions basically along the line of
basic behavioral research, science research that you are doing
but also some more specifics as far as how we can start within
our health care system, within the research that you are doing,
as we learn more and more about the functions of the brain,
what we can do to prevent and teach people how to control their
levels of stress so that we are not dealing with these chronic
symptoms that are weighing down our health care system.
There is also major science now backing in schools that
these kids that come to school, they have problems at home.
They have problems with their family. They are dealing with a
significant amount of stress before they get into the
classroom, and the brain research is showing that in these kids
the part of their brain that they need for working memory, for
good decision-making is all being affected by the levels of
stress they are having to deal with.
So I have two or three questions. One, initially, probably
would be for Dr. Briggs, I think. So, come on up.
What research have you supported and are currently
supporting on the application of low-cost behavioral
interventions such as mindfulness-based stress reduction on
health care utilization?
Dr. Briggs. Congressman, I am delighted at your interest in
this question. This is indeed a very exciting part of our
scientific portfolio. We have a very robust set of superb
applications dealing with mindfulness, stress reduction and
their impact on disease.
Dr. Davidson's program is supported by us as a center, and
he is doing very interesting fundamental neural work on the
impact of meditation on the brain.
In addition, we are looking at some very practical
applications of these methods such as effect of mindfulness on
post-traumatic stress disorder, effect on eating and metabolic
disorders and effect on the management of pain.
As I think this Committee is well aware, management of
chronic pain, and as all of us as doctors know very well,
management of chronic pain is very difficult, and these
interventions show substantial promise in that arena. It is a
very active area in our portfolio.
Mr. Ryan. My next visit is on Monday. I will be out at the
University of Massachusetts Center for Mindfulness, and I
invited Representative Kennedy to come on over and help meet
with some of the folks over there. Jon Kabat-Zinn started that
about 30 years ago, and that is dealing with managing chronic
pain.
I think this is another area that we really need to get
into.
What research are you supporting on behavioral
interventions that can start early in life, so, preschool,
first grade, to promote emotional and social skills to help
deal with these levels of stress in a lot of these kids--
basically, the emotional and social intelligence that our kids
are really required, not only required to have but need to be
competitive in a global marketplace?
Dr. Briggs. This is an area of great promise. NCCAM has a
relatively small portfolio in mindfulness in children, but I
agree with you, it is an area of great promise.
We are a small part of the NIH. We are only 0.4 percent of
the NIH budget. But we are very careful to partner with areas
like OBSSR in the development and support of the behavioral
research. It is a very promising area.
PHYSIOLOGICAL FACTORS AFFECTING ORGAN SYSTEMS
Mr. Ryan. Okay. Well, you can answer this in writing but
about the research you are supporting, focusing on identifying
how psychosocial factors can get under the skin and affect
organ systems, both for health and illness, if you can get back
to me because I know the hammer is coming down from the
Chairman here real soon. I am starting to sweat.
Dr. Briggs. We would be glad to give you that information.
[The information follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Ryan. Yes, my stress level is going up right now.
But just to say thank you and that over the course of this
budget and next year's budget this is something that I am going
to be extremely focused on and hopefully get you some more
money because I think this can end up in the long run saving
our health care system, our education system, tons and tons--
and our criminal justice system, tons and tons of money.
Dr. Briggs. This is an area that we also hope to be able to
look at in the comparative effectiveness arena.
Mr. Ryan. Great. Thank you.
Mr. Jackson. Mr. Kennedy.
Mr. Kennedy. Thank you, and I appreciate those questions
very much.
I do have a number of questions about neuroscience and the
brain and look forward to getting to those, but I fear that we
don't have enough time today but look forward to future
hearings.
I do want to ask Dr. Kington if he could present the
President of the United States with the top half-dozen most
promising opportunities to fund research that would transform
the outcomes of various diseases in terms of the research and
its production of viable cures.
I have had numbers of scientists in my office to talk about
the deficit in these research grants that you have heard the
concern about all over today in this Committee and how that
whether it is muscular dystrophy or if it is brain science or
if it is another illness and that if we had more peer review
science.
We are leaving so much of it on the table because we don't
have enough funding, that if we had more of it out in clinical
trials, that we would be moving it forward so much that we
could really make a marked difference in people's lives.
What I think we could make such a difference in this
Country in terms of funding this Committee properly is if the
President of the United States went to the American people and
he said: This is the deal. If we had these dollars, we could
literally expand the lifetime of people with this illness, with
this illness, with this illness.
We could literally find a cure for Alzheimer's. It would
shorten the time that we could find a cure for Alzheimer's in
this period of time.
We could literally shorten the period of time that we could
come up with a cure and find a cure for autism.
We could literally make the progress we need to make on
Parkinson's disease and shorten the time that we need to have a
cure for some of these other illnesses.
I think that is the way we capture the public's
imagination. It is not over jobs. It is not about jobs. This is
about changing the quality of people's lives.
I have had it put to me so poignantly on so many occasions
in my office, that it just gets me wild when I think to myself
that we can't get it across the American people that their
dollars, just a minuscule amount of dollars in comparison to
the total budget, could be transforming their health care--
transforming it--and, furthermore, cutting the amount of
dollars that we are going to have to expend in overall future
health care dollars.
You heard the other day in terms of the Alzheimer's folks
who were in town the other day. We spend so many dollars
treating Alzheimer's patients when if we just found a cure, and
the research dollars we are spending on Alzheimer's is
minuscule. It is pennies compared to the dollars we are
spending on actual treatment.
So, if you could comment just basically on that premise
that we are spending dollars on treatment of Alzheimer's and on
treatment of autism. Autism is now 1 in every 142 boys that are
born have autism. Yet, research is like pennies in Alzheimer's
and autism compared to the treatment of these diseases and why
it is that we should be spending money on the research because
the research is prevention. It is like real dividends paid if
we invest in the research.
Could you talk about that?
Dr. Kington. Well, we certainly share your passion for NIH
as a good investment for the American people primarily because
of its impact on health. All of us live healthier lives and
longer lives because of the advances certainly over the last
several decades.
I think that each of us could generate a list of diseases,
whether it is Alzheimer's or many other neurologic disease,
cancer, musculoskeletal diseases, infectious diseases and HIV,
the obesity epidemic. We could run down the list of areas of
important scientific opportunity and enormous public health
challenge.
We believe that over the course of this Agency we have been
a good investment. So I will be discreet and say that we share
your enthusiasm for this Agency.
Mr. Kennedy. What I am asking for is I need, we need to get
concrete here. We can't be all over the board. We need the
President of the United States to offer up your top, most
promising research in the pipeline and send out because the
American public can only handle a couple of really specific
examples that we can digest in the public medium.
I am asking you, can you get it to the President, so he can
put it in a speech and capture the American public's attention
on this?
Dr. Kington. Well, your point is well taken. We will think
about whether or not we can get an opportunity to do that.
Mr. Kennedy. Okay. Well, I would encourage you to do that
because it is good for your budget.
Dr. Kington. That, I can't respond to. [Laughter.]
Mr. Jackson. Ms. McCollum.
MESOTHELIOMA RESEARCH
Ms. McCollum. Thank you, Mr. Chair.
I am going to set a little bit of a background here.
Mesothelioma kills as many as 10,000 people each year in the
United States. When I am using that term, I am also going to
include other asbestos-related diseases.
Millions of Americans are exposed to asbestos, including
military personnel and approximately 1.3 million employees on
the job in construction and general industry according to OSHA.
Now many people are going to be surprised that the use of
asbestos, a known human carcinogen, has no established safety
threshold level for exposure, and it is not banned for
reimportation into the United States. So it currently comes
back in products.
Worldwide, the World Health Organization estimates that
90,000 people die each year from asbestos-related lung cancer.
So, last year, to try to see where the scientific community
was on pulling all the information together, I put in some
report language and it was as follows: The Committee is
concerned about the progress and the research and the efforts
to address mesothelioma and other asbestos-related diseases
and, therefore, requests a complete report of all NIH-related
intramural and extramural projects and grants related to
mesothelioma and asbestos-related diseases.
Are you prepared at the time or can you get back to me
shortly on the progress on research efforts to address
mesothelioma and other asbestos-related diseases through NIH?
Who could take the leadership in coordinating what is going on
out there on this disease?
Dr. Kington. We would be happy to get back with you with a
much more detailed presentation about the status of our current
portfolio and where we think are the important scientific
opportunities. As you point out, this is a relationship that
has been known for some time now, and it is something that we
can do something about.
It is an important problem, and we will get back to you.
[The information follows:]
Mesothelioma Research
Dr. Kington: Mesothelioma is a disease in which malignant cells are
found in the sac lining of the chest, the lining of the abdominal
cavity, or the lining around the heart. Most commonly linked to
exposure to asbestos, this disease usually remains asymptomatic for
many years until detected at a later stage. This limits treatment
options and results in poor rates of success. Few active therapeutic
options are currently available, and patient outcome is invariably
dismal in the short term. NCI is committed to finding new treatment
options and funds a broad research portfolio in which several areas
show promise.
Mesothelin, a protein present in limited amounts in normal tissues
but highly expressed in many cancers, makes an attractive candidate for
cancer therapy. Three mesothelin targeted agents are in various stages
of clinical evaluation in patients.
NCI scientists are conducting a clinical trial of SS1P, an immuno-
toxin targeting mesothelin, in combination with pemetrexed and
cisplatin for the treatment of newly diagnosed pleural mesothelioma.
The trial is based on previous laboratory studies showing synergy
between SS1P, taxol, and other chemotherapeutic agents.
Researchers at NCI have completed a phase I clinical trial of
MORAb-009, an anti-mesothelin monoclonal antibody and vaccine, in
patients with mesothelin expressing cancers. A multi-institutional
phase II clinical trial of MORAb-009 with chemotherapy in mesothelioma
is set to begin with NCI as the lead institution. MORAb-009 was
developed as a collaborative effort between NCI and Morphotek Inc.
NCI is also participating in a clinical trial of a mesothelin tumor
vaccine (ANZ-207) for the treatment of patients with mesothelioma who
have failed standard therapy.
The Cancer Therapy Evaluation Program of the Division of Cancer
Treatment and Diagnosis (DCTD) supports four active phase II clinical
trials under a contract with several cancer research institutions
within the U.S. Two additional phase II trials have been approved and
will be active in 2009. These studies are testing novel targeted agents
for mesothelioma, including molecules that inhibit the formation of
blood vessels in the tumors. Almost 100 mesothelioma patients have been
treated so far in these trials.
NCI has awarded a grant to the University of Pennsylvania to study
immuno-gene therapies for malignant pleural mesothelioma. Included in
this program is a phase II clinical trial combining immunotherapy,
chemotherapy, and surgery. This program is expected to produce findings
that will be incorporated as novel mesothelioma therapies.
The Radiation Research Program of DCTD has awarded a grant to the
University of California, San Francisco, to develop radio-
immunotherapies for mesothelioma tumors using nanotechnology for
specific targeting of mesothelioma tumor cells. This has the potential
to create far-reaching applications in radio-immunotherapy,
particularly in high-potent treatments for malignant mesothelioma.
The Cancer Diagnosis Program of DCTD has awarded a grant to the
University of Washington to gain a better understanding of the immune
response to ovarian cancer using an assay to detect mesothelin.
Although not specifically directed to mesothelioma, it is expected to
impact mesothelioma therapies since it is studying a target shared by
both diseases.
NCI has awarded to grants through the Small Business and Innovation
Research and Small Business Technology Transfer Programs to study
mesothelioma treatments. One grant is seeking to improve the delivery
of small interfering RNA (siRNA)-based therapeutics targeted for the
treatment of malignant mesothelioma. The other grant is seeking to
develop functional gene therapy vectors as a treatment mode for
mesothelioma.
Ms. McCollum. I would appreciate that.
Mr. Chair, there are many opportunities out there, I know,
for researchers who are looking at moving forward on this,
including at some of our universities which are facing great
struggles in that right now.
Angels dare to tread with picking out what is the most
important disease to study. The reason why I said to kind of
find out what is going on and who is collaborating and
coordinating on this is quite often because military personnel
are involved in this here too. So I am going to lay out a
little more challenge perhaps.
I see the NIH as being the lead organization in the United
States with what the Department of Veterans Affairs is doing,
what our universities are doing, what other research groups are
out there doing. Somebody has to pull this all together.
We have limited dollars, and people are coming up here. Mr.
Kennedy just pointed out some great, great opportunities to
improve the quality of lives for people, individuals and their
families with Alzheimer's, with autism. We have to get really
smart with the dollars that we have in health care.
I think people look to you, and I want to look to you as
being the leaders in telling us, the Congress, how we can go
forward and working in cooperation with you in setting up good
examples of how not only basic research but peer review
studies, as has been pointed out, and funding grants and
applications can have long-term benefits.
With that, I yield back, Mr. Chair.
Mr. Jackson. Thank you, Ms. McCollum.
Just before I recognize Mrs. Lowey, I received an update.
Votes are expected between 11:20 and 11:40. These will be the
first and last votes of the day, potentially a very lengthy
vote series.
I have a number of questions, Dr. Kington, that have been
presented by Chairman Obey and the Committee that we would like
to submit for the record and would like a detailed response to
those questions.
Dr. Kington. We would be happy to answer.
Mr. Jackson. Mrs. Lowey.
IMPACT OF TOXIC CHEMICALS ON HEALTH AND DEVELOPMENT
Mrs. Lowey. Thank you, Mr. Chairman.
The fact that I had to be at a hearing next door has
certainly not defined my passionate interest in what you are
doing at the NIH, and I am delighted to have the opportunity to
have an exchange with you, and I look forward to continuing the
dialogue. Thank you.
For years, I have been concerned about the impact of toxic
chemicals on health and development particularly in the womb
and throughout childhood. Some scientists believe these
endocrine disrupters can alter cell development and organ
function, negatively affecting one's health throughout a
lifetime.
More than 12 years ago Congress passed legislation that I
authored, requiring EPA to screen and test chemicals and
pesticides for possible endocrine-disrupting effects.
Unfortunately, EPA has moved slowly, which is the
understatement of the year, in developing techniques to
identify disrupters.
While I understand that NIH has a program to study the
impact of endocrine disrupters on humans, there are still many
gaps in our knowledge on this issue.
I know that Dr. Linda Birnbaum, the new Director of the
NIEHS, National Institute of Environmental Health Sciences,
isn't here today. But I would like you to comment on activities
within NIH when it comes to studying endocrine disrupters.
What is being done?
How can we enhance this research?
Would NIH be willing to convene a panel of stakeholders to
develop a plan for research moving forward? How much funding
would be required for this?
How will the National Children's Study specifically study
endocrine disrupters' impact on children's health and
development?
If you can respond and share any additional information,
that would be helpful.
Dr. Kington. Thank you. As you noted, Dr. Linda Birnbaum is
our new Director. She is a world-renowned toxicologist and
actually comes from the EPA.
I know they have a substantial investment of over $30
million in endocrine disrupters, both at NIEHS and the National
Toxicology Program which is run jointly with NIEHS.
They have also been a leader in the area of EPA analysis,
and their monograph on that topic is also available now. And
they are working closely with the FDA on a number of these
issues, and the EPA.
I know that Dr. Birnbaum is considering having a workshop
as a planning exercise to do exactly what you suggested--to
bring together scientists and constituencies to come up with a
reasonable sort of next step plan, both in identifying research
gaps and, we hope, to inform our decisions about allocation of
resources.
I know this is a priority topic for her. We can give back
much more detail about what we are doing in terms of specific
activities, and there is a substantial portfolio precisely
because this is such an important public health challenge.
Mrs. Lowey. Well, let me thank you very much. As I
mentioned, I began working on this when scientists came to talk
to me about it.
And I have been so concerned about the impact of wrapping
food in plastics. Recently, many mothers of newborns have been
concerned about the impact of the bisphenol A, I believe it is,
plastic bottles. So I do hope that there is an urgency at the
NIH to finally address these very serious issues.
Dr. Kington. It is certainly a priority.
Just as another example of ways that we are trying to help
develop informed policy about this, we have started an
initiative with the FDA in which we will take existing NIH
studies that have biologic samples that can be analyzed to look
at the relationship between BPA, bisphenol A, and various
health outcomes. We are hoping that by using existing data sets
and existing studies, we can develop quickly more information
that will help inform some of FDA's decision-making.
Mrs. Lowey. Well, thank you.
It has also been widely acknowledged in the medical and
scientific communities that this generation of children may
face a lower life expectancy than their parents due to
increased obesity and decreased physical activity.
I would be very interested in whether the National
Children's Study will look at what factors, both genetic and
environmental, might contribute to increased incidence of
obesity, and I would be interested to know because there is
another issue that many of us have been talking about for a
very long time and not that there hasn't been attention given
to it.
I see the red light is on. Maybe you can just respond very
quickly. What research is NIH doing on this topic?
Dr. Kington. It is certainly a priority. It is among the
most important problems facing our population with the
potential of having substantial detriments in health as a
result of this aging cohort that is becoming adults, carrying
with them the weight of overweight and obesity and all of the
health implications that come with that.
I know that it is one of the topics that is to be studied
in the National Children's Study, and we also have a range of
community-based interventions that are being developed as well,
particularly targeted toward activity in children as
adolescents when they begin to develop their health habits for
their lives.
So it is an important topic. We can give you a lot more
detail about the full portfolio of investment in that area.
Mrs. Lowey. Thank you.
I just want to say, Mr. Chairman, that we have been having
these hearings for a long time, and Dr. Fauci just gets in
better shape and better shape. He looks younger every time.
Dr. Kington. It is because of NIH research that he looks so
good. [Laughter.]
Mrs. Lowey. Thank you.
Mr. Jackson. Let me thank you, Chairwoman Lowey.
We have time for a brief second round requested by the
Minority, but let me first acknowledge and recognize for five
minutes under the first round, Ms. Lee.
Ms. Lee. Thank you very much, Mr. Chairman.
I apologize for being late. So, if the question is
redundant, please forgive me.
I am looking at your testimony, and I will definitely read
it. It is very good to see you.
Dr. Kington. Great to see you.
OUTREACH FOR MINORITIES IN RESEARCH PROFESSIONS
Ms. Lee. Thank you for being here. And all of the NIH
directors and staff, thank you for the work that you are doing
to advance research and quality medical care which your
research, of course, is allowing us to do.
Also, I appreciate the urgency and the diligence that NIH
is putting into using the funds that we provided in the
economic recovery package.
I am particularly concerned--I am sure you know that--that
as we dole out these funds that we are especially mindful and
assured of the fact that they will benefit all segments of our
diverse population. We are all aware and we know that it has
been very difficult for minorities to break into the research
professions and compete for NIH grants.
So I just want to just ask you with regard to the specific
funds with regard to diversity, how you plan to ensure
diversity among the new investigators that will benefit from
the funding in the economic recovery package and also if you
have specific, I guess, outreach efforts for African American,
Latino, Asian Pacific American and Native American and other
racial minority groups represented among these investigators.
Are you coordinating these efforts among the institutes?
And, finally, extramural research facilities, I want to
make sure that minority-serving institutions such as Meharry
Medical School know about funding opportunities and are able to
compete for these funds because we are at the beginning and at
the dawn of a new day now. So I would like to see some of the
past history, for whatever reason, of lack of diversity, lack
of inclusion be rectified and corrected as we move forward in
this new era of change.
Thank you very much.
Dr. Kington. Well, it is certainly true that we believe
that it is essential that we have a diverse workforce in order
to achieve our goals of the next generation for science. If we
don't do it, we won't make the progress that we need to make. I
think we try to focus on integrating approaches throughout the
various programs.
One area that I think has great opportunity is our summer
program for summer jobs. This is an opportunity for thousands
of students to work in labs in the Summer of 2009 and the
Summer of 2010. We are just developing an outreach program, and
the highest priority is to reach out to students who are from
under-represented minorities and other diverse backgrounds as
well as from geographically diverse areas as well.
This is a great opportunity. We are just planning it now
and working collaboratively across the institutes and centers.
In terms of the construction, all of the institutions will have
opportunity to prepare proposals.
We have $1 billion that is being devoted. Obviously, we
will make a significant effort to ensure that there is a
reasonable spread of those funds across types of institutions
and across the Nation. So I think we are aware of a lot of
these issues.
And some of the institutes are specifically targeting their
training programs and their diversity programs for additional
resources. For example, the National Center for Research
Resources which funds the RCMI program, which is a target
program to support research centers at minority institutions
and which has a base of about $300 million will get about $70
million more dollars through supplements.
So we are trying to use all the mechanisms that we can use
to make sure that we are diverse, both scientifically and
geographically and along other dimensions as well.
We, of course, have a continued problem with the pipeline,
and that is a real issue in terms of assuring that we have
diversity at every stage of the career development process. It
is very clear that the diversity that we are seeing at the high
school level is not translating to the diversity that we see at
the level of principal investigators of grants.
We are, in particular, interested in funding a program that
will encourage diverse and creative approaches, new approaches
to addressing some of these problems. We know that there are
models that work, but it has been a real challenge for the
scientific community as you are well aware.
There isn't a magic bullet, but we are committed to trying
new approaches.
Ms. Lee. Thank you.
Mr. Jackson. Ms. Lee, thank you.
I understand that we have time, and it has been requested
for an abbreviated second round. I am going to limit members'
comments, if they don't mind, to three minutes.
I believe we do have time before the series of votes
begins, and I am going to show some leadership by example on
that three minutes.
Let me first begin by saying I want to change my focus to
the National Center for Research Resources. In the American
Recovery and Reinvestment Act of 2009, the Congress made an
investment in the research infrastructure of our Nation's
universities and colleges by placing $1,000,000,000 in an
extramural facilities account at NCRR which had not been
previously funded since fiscal year 2005.
I want to further make you aware that the Public Health
Service Act says the following: ``Up to $50 million, the
director of the Center shall make available 25 percent of such
amount to'' emerging centers of excellence.
Since this program has not been funded in so long, I want
to remind you that these institutions such as Meharry Medical
College, Morehouse School of Medicine and Charles Drew
University, which focus on eliminating health disparities,
which is a priority for the NIH.
Can you assure me that NIH will follow the letter of this
law in the way it distributes the funds of this competitive
grant program?
Dr. Kington. We will follow the letter of the law. I am not
familiar with that specific part of our law, but we will go
back and review it, and we will follow it to the letter.
Mr. Jackson. The reason I am putting this question in the
record is because I wanted to familiarize you with it and put
it on your mind that because we have expectations in this
Committee that the law be followed.
Also, I want to congratulate the NIH for organizing an
impressive summit on health disparities in December. In
particular, I want to commend Dr. Ruffin and the Center on
Minority Health and Health Disparities--would you please take
your seat--for their vision and leadership in planning such an
important conference.
The summit was a major accomplishment for the National
Center for fulfilling the spirit of the law by bringing
together all the institutes and centers at NIH and other
Federal agencies around health disparities, but this is the
type of leadership and coordination that the National Center is
charged with and must continue to demonstrate with your support
and the cooperation of the institutes, Dr. Kington, and the
centers.
At the summit, you announced the creation of the Health
Disparities Intramural Research Program at the National Center.
It is good to know that the research into health disparities is
becoming more prominent at NIH's campus under the leadership of
the National Center.
I am always concerned about the support and resources of
the National Center to effectively carry out its leadership
responsibilities for minority health and health disparities at
NIH. What additional resources have you given or planned to
give to the National Center to start its intramural program or
enhance its coordination?
I would like you to answer it very quickly and then, Dr.
Ruffin, if you would comment, and then Mr. Tiahrt is
recognized.
Dr. Kington. First of all, I had the pleasure of actually
announcing that program at the summit. We think that is a great
need, and it is an interesting model, a new model that I think
some of the other institutes may follow as well in seating
scientists across institutes and centers and having, if you
will, sort of a virtual network across the institutes and
centers rather than starting a new stovepipe.
I think that is a great model. It has been fully supported
by Dr. Zerhouni and Dr. Michael Gottesman, the Intramural
Program Director, and we worked collaboratively with Dr. Ruffin
to develop it. We will continue to support it.
Mr. Jackson. Dr. Ruffin.
Mr. Ruffin. As you know, most of our effort, not being a
disease-based center but a trans-NIH center, that much of our
success depends upon our ability to work collaboratively with
all of the institutes and centers at NIH. And so, with the
intramural program, we will continue that effort and work
across NIH to make sure that this comes across the way we
intend it to be.
Mr. Jackson. Thank you.
Mr. Tiahrt for three minutes.
COMPARATIVE COST AND COMPARATIVE EFFECTIVENESS IN RESEARCH
Mr. Tiahrt. Thank you, Mr. Chairman.
I noticed in your written testimony, Dr. Kington, that you
have been tasked with doing comparative effectiveness research
and received $400 million to do it. Will this include
comparative cost effectiveness in research?
Dr. Kington. The definition for comparative effectiveness
research was defined in the legislation, although there is a
range of definitions.
We identified that as one of the priority areas within the
Challenge Grants Program. If we receive high quality
applications that meet the definition for comparative
effectiveness research that include cost, we will fund them. We
may not fund them with the $400 million set aside. That will
depend upon the ultimate decisions about the definition that
will apply to that pool of funds.
Mr. Tiahrt. So you are not certain at this point whether
cost comparative research will be part of it? It could be?
Dr. Kington. It could be.
Mr. Tiahrt. My concern is this, and I hope that you don't
fund it.
I just spoke recently with a young lady named Jenny Jobe.
She has an immune deficiency. When she turned 65, Medicare
denied her current medication and put her on something that was
more cost-effective.
It gives her headaches. It gives her backaches. She has an
upset stomach, and it doesn't work. Because of it, her immune
system can't fight off a lot of the common things that we are
able to disperse.
My point is that cost comparative research will lead to
rationed health care. Medicare is rationed health care today.
She is a good example. There are many other examples.
Medicaid does the very same thing.
As we approach what people will call universal health care
or single payer health care or national health care, it will
become rationed health care very easily. I think it will
anyway.
But if you go to cost comparative or cost-effectiveness
research, it will lead directly to that path, and people who
have very serious diseases will be denied the best treatment.
With the oncoming of the genome mapping, the DNA now that
each of us possess, which is unique to all of us, allows us
individual treatment. But cost-effectiveness research will lead
away from that individual treatment and group us in aggregates.
My concern is that these aggregates will not be able to meet
the needs or the science that we have today.
Dr. Kington. Well, certainly as a physician who practice
internal medicine I certainly understand the concern that any
policy effort might severely restrict choices in whatever way,
but comparative effectiveness research doesn't necessarily lead
to that.
Mr. Tiahrt. Right.
Dr. Kington. Comparative effectiveness research can provide
useful information to commissions, to patients and providers to
make better decisions about what works, under what
circumstances, for which patients and might actually complement
the movement that you noted toward personalized medicine. So
they are not necessarily opposing.
We believe that comparative effectiveness research will
increasingly integrate information at a much more detailed
level, at the individual level and can be used to help make
better decisions for everyone. But I certainly recognize the
concern.
Mr. Tiahrt. Thank you, Mr. Chairman.
And thank you, Doctor.
Mr. Jackson. Mr. Honda for three minutes.
Mr. Honda. Thank you, Mr. Chairman.
A real quick question on climate change and the kind of
work that we are doing. Is there any thought being done on
using some of the funds--even though if it is a two-year
project, I know it will have continuous impact--in looking at
climate change, its impact on immigration patterns and then
ultimately spreads of diseases and things like that, working
with NASA, NOAA and some of the others, CDC? Is there any
thought or are there any grants that would be addressing that
arena?
Dr. Kington. First of all, the public health community is
becoming increasingly aware of the potential impact of climate
change on health, and it is potentially extraordinary--
everything from increasing heat waves and individuals who are
vulnerable to high temperatures such as the elderly at risk of
heat strokes to changes in ecologic systems that might, for
example, increase the transmission season for vector-borne
diseases such as diseases carried by mosquitoes all the way
through to drought and malnutrition.
We have begun a process of assessing what our own portfolio
is in the Agency. The Fogarty International Center is actually
chairing a working group of individuals from across the Agency
to look at what our current investments are and to think about
new investments.
Certainly, this is an important scientific area, and it
could be eligible for funds either through existing grants or
newly submitted grants as a result of ARRA dollars. So it can
be funded under ARRA dollars. Thus far, it has not been an
explicitly articulated area of focus, but researchers can
submit under many of the initiatives and can submit their own
ideas for ARRA dollars.
This is an important scientific area. Again, though, I
think we are at the early stages in terms of the research
community in understanding what the big needs are. Many of the
institutes already have large portfolios. NIAID, Dr. Fauci's
institute, deals with many of the infectious diseases, and I am
certain would be able to fund research related to this.
I don't know if you would like to comment.
Mr. Honda. Yes, I would hope that we would be anticipatory
rather than reactionary. I think that knowing the information
that we have at hand and using computer-assisted predictions,
that your NIH has a role in trying to figure out what it is
that we can anticipate.
Dr. Kington. We agree.
Mr. Jackson. Mr. Ryan for three minutes.
BASIC BEHAVIORAL AND SOCIAL SCIENCE BLUEPRINT
Mr. Ryan. Thank you, Mr. Chairman.
I understand from some press accounts that you asked two of
your institute directors, Jeremy Berg and Richard Hodes to come
up with a basic behavioral and social science blueprint. Could
you provide the Subcommittee with some more details on this
initiative and when you expect the effort to be completed?
Dr. Kington. Of course. As you know, there has been a
running discussion at the Agency about how best to support
basic behavioral and social science research. There is no
question that this is important for many of our major areas of
focus at the Agency. Certainly, lots of prevention hinges on
changes in behavior, and basic behavioral and social science
research informs how we understand these behaviors occur and
how we develop interventions to prevent bad outcomes.
I think there was a decision made that I fully support,
that rather than putting all of this area into one unit at the
Agency, it is so important for so much of the Agency's mission
that it should be spread across the entire Agency. This is a
challenge we have had for many areas like this--obesity, the
neurosciences--where we know there are important scientific
opportunities that cut across the structure of the Agency.
So we are following a model that we developed. We use it in
obesity. We also use it for the neurosciences blueprint, where
we form a high level of leadership. In this case, as you
pointed out, co-directed, co-chaired by Dr. Berg and Dr. Hodes
of the Aging Institute but also populated by institute and
center directors, in which we look for strategic opportunities
to build areas of research where there are gaps and that have
the potential to affect the missions of multiple institutes and
centers.
The expectation is we will have both a core funding at the
institutes and centers, and there will be a pooled funding as
well. This is just getting started now and will be playing out
over the next year, but then the blueprint will set the stage
for research over several years.
I think this is the right approach. Dr. Berg and Dr. Hodes
are committed to making this work. We have seen it work before.
Stay tuned. You will see major changes.
Mr. Ryan. Also, in the report language that we had in 2009,
we asked for a progress report by March 1st of this year, I
think, asking you to use the Division of Program Coordination,
Planning and Strategic Initiatives as the central headquarters
to do this. So, if you could give us some insight as to what
the report will entail.
I just say I think a lot of people in the field, whether it
is stress reduction or mindfulness or social and emotional
learning or behavioral science, in many instances are doing
this already. I think it is our responsibility as policy makers
to try to break down these walls and get it into the prevention
side of our health care plan, with the insurance industry and
what we are doing here.
So I appreciate what you are doing. Any assistance we can
be, we want to be helpful.
Dr. Kington. Can I just note that one of the areas in the
Challenge Grants is behavior change and prevention? So that is
one of the fifteen areas that is targeted.
Also, in our Transformative RO1 Program that is designed to
fund really creative and innovative research, we also
specifically ask for applications on the science of behavior
change. So I assure you it is at the top level of consciousness
of the Agency.
Mr. Ryan. That is not locked into one institute?
Dr. Kington. No.
Mr. Ryan. That is across the board.
Dr. Kington. The common fund and across the Agency.
Mr. Ryan. Okay. Great. Thank you.
Mr. Jackson. Votes are coming now. We do have time to
finish this round of questioning, provided no other members
enter the room.
Mr. Kennedy, then Mrs. Lowey, then Ms. Lee for three
minutes.
COORDINATION FOR TBI AND PTSD
Mr. Kennedy. If Dr. Landis could come up.
I would like to thank Dr. Kington.
I really want to thank my colleague, Mr. Ryan, for his
focus on behavioral health.
I want to focus on the Institute of Neurological Disorders
and ask Dr. Landis, in light of the soldiers coming back from
Iraq and the traumatic brain injury--360,000 of our soldiers
suffering from traumatic brain injury--can you talk about the
coordination that is going on between NIH, DOD, the VA and to
what extent that we can get all the brain science together,
neuroscience research and brain research and how that research
can, interrelated, work to benefit psychiatric disorders?
Mr. Landis. There is a significant effort in NINDS to look
at Traumatic Brain Injury (TBI) at the cellular, molecular
level all the way to understanding changes that may occur in
brain structure and brain connectivity.
NINDS, as the lead institute for that, has worked very
closely with the Veterans Administration and with the DOD to
make sure that there is not duplication but that there is
actually good gap analysis, and programs have been targeted to
specific topics. Towards that end, we have been working in
workshops with diagnosis of TBI, definition of what actually
brain changes occur, coming up with common data elements that
would allow us to do clinical trials.
Of particular interest is a very new effort coordinating
with USUHS, Uniformed Health Services Institute, the Naval
Hospital--and, as you know, Walter Reed will be moving out to
the Naval Hospital--with the NIH to come up with a very
innovative program to look at TBI and Post Traumatic Stress
Disorder (PTSD) and better ways to treat it. So I think there
is a lot going on.
[The information follows:]
Coordination for TBI and PTSD
Dr. Landis: The new Center for Neuroscience and Regenerative
Medicine (CNRM) is explicitly designed as a coordinated program of NIH
and the Uniformed Services University of Health Services (USUHS). A
Memorandum of Understanding spells out in detail how the center will
operate as a cooperative venture. In keeping with that agreement, Dr.
Kington appointed a steering committee that includes the directors of
NIMH, NINDS, the NIH Clinical Center and General Sutton of the Defense
Center of Excellence for TBI. The research will help the soldiers at
Walter Reed and National Navy Medical Center using the extraordinary
neuroimaging resources at the NIH Clinical Center and the collective
efforts of 162 investigators from USUHS and from several NIH
Institutes. Plans are moving forward for research on diagnostics,
biomarkers, neuroprotection, regeneration, and rehabilitation, as well
as patient recruitment, informatics, and other critical areas.
More generally, there is extensive coordination of research on TBI
and PTSD within NIH and among NIH and the Department of Defense, the
VA, the CDC, and other federal agencies. At NIH, NINDS, NIMH, and the
National Center for Medical Rehabilitation Research, which is within
NICHD, each have major TBI or PTSD programs, and other Institutes
participate as appropriate. A Federal Interagency TBI Research group
informs federal agencies of one another's efforts and facilitates
coordination. A September 2008 meeting of the group discussed goals,
priorities and funding for TBI research across many agencies including
the NIH, four components of the DoD, the VA, CDC, SSA and others. Other
trans. agency workshops have focused on TBI Classification in October
2007, Combination Therapies for TBI in February 2008, on Neurological
Consequences of Blast Injury in April 2008, Trauma Spectrum Disorders:
Effects of Gender, Race, and Socioeconomic Factors in August 2008, and
Advancing Integrated Research on Psychological Health and TBI: Common
Data Elements in March 2009. The NIH is working closely with CDC on the
activities specified in the TBI Act of 2008, including studies on how
to improve tracking of TBI in former military personnel and on the
effectiveness of interventions. There are many other interactions among
the staff of the various agencies, including, for example, sharing of
expertise and knowledge on review panels and on advisory boards for
clinical consortia. For many years, the NINDS intramural research
program has conducted very important work with the VA and DoD on long
term neuropsychological outcomes of TBI in Vietnam veterans, and now
the memorandum will further enable that research to extend to veterans
who served in Iraq and Afghanistan.
Finally, at the broadest level, the NIH Blueprint for Neuroscience
Research coordinates the efforts amoung the 16 NIH Institutes, Centers
and Offices that support neuroscience research. Just as the NIH Roadmap
for Medical Research addresses roadblocks that hamper progress across
all of medical science, the Blueprint takes on challenges in
neuroscience that are best met collectively.
The Blueprint has developed working groups on specific cross
cutting issues, brought the scientific community together in scientific
workshops, funded grants and contracts through specific initiatives,
developed tools and resources to help all neuroscientists, and
generally fosters communication and a culture of cooperation within the
NIB and the neuroscience community.
Mr. Kennedy. Is it being run out of NIMH because NSF told
me there is a blue kind of an unofficial organization of brain
science kind of being done through NIMH, or coordinated.
Mr. Landis. There is a coordinated effort. So, NINDS has
responsibility for TBI, NIMH for PTSD, and we recognize that
the same changes in brain structure may underlie both, and we
are working very closely together to maximize our understanding
of brain plasticity to make a difference for soldiers who are
coming back with both of those disorders.
Mr. Kennedy. I would just like if you could get me what is
going on in terms of coordination.
Mr. Landis. Absolutely. I will give you a detailed answer
for the record.
[The information follows:]
Asthma and Allergy Diseases
Dr. Insel: The National Institute of Allergy and Infectious
Diseases (NIAID) continue to build on its longstanding and successful
research efforts into the causes, pathogenesis, diagnosis, treatment,
and prevention of asthma and allergic diseases. NIAID vigorously
pursues research on asthma and allergic diseases by supporting
investigator-initiated projects, intramural research, cooperative
clinical studies, networks of research centers, and demonstration and
education research projects. The ultimate goal of NIAID's asthma and
allergic diseases research programs is to develop more effective
therapies and prevention strategies.
An important example of the many NIAID initiatives in asthma and
allergic disease research is the NIAID-supported Inner-City Asthma
Consortium (ICAC), which evaluates the safety and efficacy of promising
immune-based therapies to reduce asthma severity and prevent disease
onset in inner-city children. The ICAC is conducting several large
clinical studies of asthmatic children and adolescents. These studies
are testing the safety and efficacy of experimental treatments for
asthma with an emphasis on factors that contribute to asthma severity
in inner-city environments. Another ICAC study of more than 500
children enrolled since birth examines the environmental conditions and
immunological responses that contribute to the development of asthma
and allergies in the first years of life. Since the 1970s, NIAID has
supported the Asthma and Allergic Diseases Cooperative Research
Centers, a network of 15 academic research centers located across the
country. These Centers currently are conducting studies of the roles of
infections, pollution and allergens in the development and severity of
asthma. The Centers also are conducting three clinical studies in
asthma, allergic rhinitis (hay fever) and sinus disease. Two additional
studies are exploring the links between genetics and asthma. Recently,
NIAID and several other NIH Institutes have established a public-
private partnership with the Merck Childhood Asthma Foundation to
define and prioritize asthma outcomes, information will be used in
future clinical studies. These outcomes will provide the
standardization needed to conduct meta-analyses and draw more
meaningful conclusions from the results of independent studies.
Another important component of the NIAID research program is in the
area of food allergy. the Consortium of Food Allergy Research is
conducting a study with more than 500 infants to identify factors
associated with allergies to peanuts, milk, and eggs. Five clinical
trials currently are underway in the consortium to evaluate the safety
and efficacy of experimental approaches to treat food allergy. The
NIAID-sponsored Immune Tolerance Network currently is conducting a
clinical trial with more than 600 infants at high risk for developing
peanut allergy to determine if eating peanut-containing foods starting
in infancy will prevent this disease. Another NIAID-supported network,
the Atopic Dermatitis and Vaccinia Network, is identifying the
immunologic changes that contribute to atopic dermatitis (an allergic
disorder commonly known as eczema) and to the heightened susceptibility
to infection in individuals with this disorder.
Recently, NIAID and U.S. Food and Drug Administration co-organized
a meeting of experts to identify safe approaches for developing new
treatments for food allergy. A report and the recommendations of this
meeting will be published this year in the Journal of Allergy and
Clinical Immunology. Lastly, NIAID is leading an effort to develop
clinical practice guidelines for the diagnosis and management of food
allergies, involving an independent evidence-based review of the
literature, guidelines writing by an expert panel, and review and
oversight by a coordinating committee of more than 30 federal agencies,
professional societies and patient advocacy groups.
SELECTED DISEASE RESEARCH AND EPSCOR
Mr. Kennedy. In terms of, Dr. Kington, if you could just
get me what is going on in terms of research on the asthma,
ADHD, allergies and autism and whether states with EPSCoR
receive any additional consideration for applying for stimulus
funds, that would be terrific.
Dr. Kington. We will prepare the response.
[The information follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Jackson. Mrs. Lowey for three minutes.
CROSS CUTTING RESEARCH
Mrs. Lowey. Dr. Kington, you and I agree that peer reviewed
medical research is at the core of NIH's mission. Peer review
grants to doctors and scientists throughout the Country are
absolutely critical to make progress in finding a cure for
treatments for thousands of diseases and disorders.
But I understand that about $800 million of NIH's stimulus
funds will go to the Office of the Director for various
research grants on various diseases. Can you share with the
Committee what your priority areas are for these funds?
How many new grants do you expect to be funded?
And, will you be able to use any of the stimulus funds to
place a few big bets on promising but risky research that you
would not have been able to pursue otherwise?
Dr. Kington. We are in the early stages of planning for the
entire allocation of $800 million, but we are focusing
precisely on those areas--areas that cut across the mission of
institutes and centers, areas where an infusion of large
dollars can move a whole field ahead and riskier investments.
So we have committed $200 million toward the Challenge
Grants Program, again targeted to those specific areas.
We have committed $100 million to the Grand Opportunities
Program which we anticipate and under which we will receive
many creative, large grant applications.
We won't make the final decisions of allocation until we
see what institutes and centers have done because then we can
decide, look at the entire portfolio and see what gaps there
are.
We are also funding the summer program for students from
the Office of the Director. That is $21 million, right now, and
it may go higher if we get more applications.
So we have made those commitments for about half. The other
half are waiting until we have a better idea of what the
commitments are of the institutes and centers, and then we can
make decisions about which initiatives we will fund.
We generally won't fund at an individual grant level, but
we will fund specific institutes' and centers' initiatives that
have broad application and cut across the mission of institutes
and centers. We are making those decisions, and we will try to
complement the decisions of institutes and centers.
Mrs. Lowey. Thank you very much.
Mr. Jackson. Ms. Lee for three minutes.
SICKLE CELL TESTING
Ms. Lee. Thank you very much.
Could I ask Dr. Rodgers to come forward just a minute,
please? Let me just thank you, first of all, and the National
Institute of Diabetes and Digestive and Kidney Diseases for
responding with regard to the whole issue of sickle cell anemia
and the validity of the A1c test.
I just wanted to know. First of all, I think the public
awareness campaign to educate the public about that was
effective, and it was very good, and I just needed an update
from you on the status of laboratories and physicians and
others who need to know this information. Do they all know now
or do we need to do more? What is going on?
Dr. Rodgers. Well, thank you for the question.
The question relates to using hemoglobin A1c. I think that
you posed to me two years ago that some were using that to
actually diagnose diabetes and it was particularly confounding
in patients that had hemoglobin variance such as sickle cell
trait.
While A1c determination is certainly not the standard at
the moment for diagnosing diabetes, it certainly is very
important for monitoring the course of disease because it gives
the average value of glucose control in the preceding two to
three months.
At the time that you asked me the question, there were
about 20 various assays for measuring hemoglobin A1c, and
unfortunately 6 of that 20 were unreliable, gave unreliable
results in individuals that had sickle hemoglobin or other
variants.
The NIH did, with your prompting, develop this education
campaign which got out the message to individuals, to
physicians as well as the general public, and it has been quite
effective in diminishing the utilization of those unreliable
methods in those areas.
We have ongoing funding to a national glyco-hemoglobin
standardization program out of the University of Missouri that
continues both looking at the final remaining assays as well as
getting the message out not only in this Country but worldwide
because of course there are many more people in other areas of
the world that have hemoglobin variants than in the United
States.
So your prompting that question, I think, has had a major
impact.
Ms. Lee. Thank you very much and thank you so much for your
responding so quickly to that because many, many people were
being, I think, mistreated as a result of that.
Dr. Rodgers. Thank you for your interest.
Mr. Jackson. Let me remind members that they may submit
questions for the record which will be provided to Dr. Kington
for an appropriate response to the Committee in writing.
I want to thank the members' indulgence as well as Dr.
Kington for allowing me to chair my first Labor, Health and
Human Services Subcommittee.
[Applause.]
Mr. Jackson. And, to all of the distinguished scientists,
chairmanships around this place are very hard to come by. It
has taken me 10 years to sit in this seat.
I am reminded by Chairman Obey that I long one day to have
my picture hanging in this austere body, and Chairman Obey
reminds me that members of Congress usually get hung before
their pictures do. [Laughter.]
The Committee is adjourned.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Wednesday, April 1, 2009.
PATHWAY TO HEALTH REFORM: IMPLEMENTING THE NATIONAL STRATEGY TO REDUCE
HEALTHCARE-ASSOCIATED INFECTIONS
WITNESSES
PANEL 1: DEPARTMENT OF HEALTH AND HUMAN SERVICES
DR. DON WRIGHT, PRINCIPAL DEPUTY ASSISTANT SECRETARY FOR HEALTH, U.S.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
DR. RICHARD BESSER, ACTING DIRECTOR, CENTERS FOR DISEASE CONTROL AND
PREVENTION
DR. CAROLYN CLANCY, DIRECTOR, AGENCY FOR HEALTHCARE RESEARCH AND
QUALITY
Mr. Obey. Good morning, everybody.
Let me welcome our panelists for the hearing today.
We have a problem in this Country. When people go to the
hospital, we hope that they are going to be made well. Instead,
to put it bluntly, there are a hell of a lot of people who wind
up being made sick and some of them dying.
CDC estimates that there are 1.7 million healthcare
associated infections in American hospitals each year, with
99,000 associated deaths affecting 5 to 10 percent of
hospitalized patients.
To me, that is absolutely shocking, when you read the
literature and you see what simple steps could be taken in many
cases to reduce this threat. We are spending billions of
dollars and focusing an incredible amount of energy to prevent
this Country from being hit by al Qaeda again. The average
American has one hell of a lot better chance to be killed by a
hospital infection than being impacted by al Qaeda.
When I look at the simple steps that could be undertaken in
order to reduce this calamity, I am reminded of the old movie
about Dr. Pasteur, who was simply trying to teach the medical
profession to wash their hands. I know it is not that simple,
but I do not believe that there has been a sufficient sense of
urgency on this issue, either on the part of Congress or on the
part of administrators throughout the government, and certainly
on the part of health providers.
I remember Paul O'Neill, the first Secretary of the
Treasury under President Bush, started to get interested in
this issue in Pittsburgh and expressed frustration at how hard
it was to move the needle.
So we are here today to talk about this problem. I have got
a much longer, windier open statement than I care to deliver
today, so let me simply say we are here to try to hear from
these two panels about what we can do to solve a huge medical
problem in this Country.
Before I call on the first panel, let me simply ask Mr.
Tiahrt for whatever comments he might have.
Mr. Tiahrt. Thank you, Mr. Chairman. I want to welcome all
the witnesses today. I would also like to point out that our
Chairman has now served in the United States House of
Representatives for 40 years, and I find that an incredibly
great record, something to admire and----
Mr. Obey. Some people might think it is horrifying.
[Laughter.]
Mr. Tiahrt. Well, it is comforting to me to know that the
national parks, which you love so dearly, have trees who have
not been here as long as you have.
Mr. Obey. Thanks a lot. [Laughter.]
Mr. Tiahrt. Mr. Chairman, this is a particularly
interesting topic to me. There is a thought, when we go to the
hospital, that we are going there to get well. Unfortunately,
for 1.7 million people, they acquire an infection while they
are in the hospital attempting to get better.
I know that the hospitals are very concerned about that and
work to try to turn that around. Our job in this Committee, I
think, is to determine how the Federal Government can assist,
and not hinder, implementing safety protocols. Sometimes we
make it more difficult, more complicated, more inefficient, and
less responsive, and I think we do not have to do that. I think
we can be assisting in this process, and hopefully that is what
we will do.
I know that there is need for guidance and incentives from
the experts at AHRQ, and the public needs the information from
the CDC. But we need to find a balance that allows the
providers to be innovative and flexible in their response,
while keeping patients healthy.
I look forward to the testimony. I think this is a very
important hearing.
I yield back.
Mr. Obey. Thank you.
The first panel is made up of Department of Health and
Human Services officials who are taking the lead in
administering programs at the Federal level focused on
understanding the problem: Dr. Don Wright, Principal Deputy
Assistant Secretary for Health, U.S. Department of Health and
Human Services; Dr. Richard Besser, Acting Director, Centers
for Disease Control and Prevention; and Dr. Carolyn Clancy,
Director, Agency for Healthcare Research and Quality.
Additionally, Dr. Thomas Valuck, Medical Officer and Senior
Advisor to the Center for Medicare Management; and Mr. Thomas
Hamilton, Director of the Surveys and Certification Group from
the Centers for Medicare and Medicaid Services are available, I
am told, in the first row immediately behind the witnesses, to
answer questions if any of our panelists decides they want to
duck a question or simply turn it over to somebody who can
buttress their answer.
With that, why do we not proceed with Mr. Wright first?
Dr. Wright's Opening Statement
Dr. Wright. Good morning, Chairman Obey, Ranking Member
Tiahrt, and other distinguished members of the Committee. I am
Dr. Don Wright, the Principal Deputy Assistant Secretary for
Health in the Office of Public Health and Science at the U.S.
Department of Health and Human Services. Let me say I am
pleased to be here today to describe HHS's efforts to reduce
the rates of healthcare-associated infections and also the
development of the HHS Action Plan to Prevent Healthcare-
Associated Infections which was released in January 2009.
There are several agencies in HHS that have played a
significant role in addressing this important public health
challenge, including the Centers for Disease Control and
Prevention, the Agency for Healthcare Research and Quality, and
the Centers for Medicare and Medicaid Services.
Healthcare-associated infections are infections that
patients acquire while receiving treatment for medical or
surgical conditions. They occur in all settings, including
hospitals and ambulatory surgical centers.
These infections are associated with a wide variety of
causes, including the use of medical devices such as catheters
and ventilators, from complications following surgical
procedures, and from transmission between patients and
healthcare workers. They exact a significant toll on human life
and are among the top 10 leading causes of death in the United
States.
In addition to the substantial human suffering caused by
healthcare-associated infections, the financial burden
attributable to these infections is staggering. Healthcare-
associated infections result in an estimated $28,000,000,000 to
$33,000,000,000 in excess healthcare dollars each year.
Despite these sobering facts, healthcare-associated
infections are largely preventable. Broad implementation of
prevention guidelines can result in reductions in healthcare-
associated infections, which not only save lives and reduce
suffering, but can result in healthcare cost savings as well.
DEVELOPMENT OF THE HHS ACTION PLAN
Successful infection prevention and elimination efforts
have been underway for years at the various agencies of HHS.
However, in 2008, HHS began a Department-wide effort to
approach this issue. HHS established a senior-level Steering
Committee for the Prevention of Healthcare-Associated
Infections last year in order to improve and expand HAI
prevention efforts. The Steering Committee is chaired by me as
the Principal Deputy Assistant Secretary for Health within the
Office of Public Health and Science in the Office of the
Secretary.
Last year, we were charged with developing the HHS Action
Plan to Prevent Healthcare-Associated Infections in hospitals.
The Plan establishes national goals and outlines key actions
for enhancing and coordinating HHS-supported efforts, and also
outlines opportunities for collaboration with external
partners.
A critical step in the Action Plan development process was
the identification of priority measures and five-year national
prevention targets for assessing progress in HAI prevention.
The targets serve to enable us to evaluate progress and focus
prevention efforts in order to achieve the goals outlined in
the Action Plan.
While there has been considerable activity across HHS
related to the prevention of healthcare-associated infections,
clearly, more work needs to be done. The Steering Committee
will next focus its second tier efforts on the ambulatory
surgical setting. Ambulatory surgical centers have been the
fastest growing provider type participating in Medicare.
FY 2009 FUNDED ACTIVITIES OUTLINED IN THE ACTION PLAN
With the $5,000,000 in funding provided to the HHS Office
of the Secretary in the fiscal year 2009 Omnibus Bill, OPHS
plans to continue the valuable work of the HHS Steering
Committee for the Prevention of Healthcare-Associated
Infections. The Steering Committee will have the continued
responsibility for coordinating implementation of the current
Action Plan, monitoring progress in achieving the national
goals of this plan, as well as leading tier two efforts. In
addition, the Steering Committee is coordinating the use of
HAI-related American Recovery and Reinvestment Act 2009 funds.
OPHS also plans to use the Omnibus funds to develop and
implement a nationwide campaign to raise awareness of the
importance of addressing healthcare-associated infections. The
campaign will focus on empowering consumers to be active
participants in preventing healthcare-associated infections and
encouraging them to be more involved in their own healthcare.
We acknowledge that some of the information on preventing HAIs
may be too technical or not accessible for healthcare
consumers, and we have identified health literacy as an
important component of health communication to the consumer.
Remaining OPHS funds will be provided to a variety of
interagency projects, all directly linked to the Action Plan.
One such example is an information systems project designed to
support a standards-based solution for integrating data
collection across specific HHS data systems. The intent of this
project is to use interoperability standards to reduce siloed
departmental data systems and reduce data collection and
reporting burdens for healthcare facilities.
Fifty million for HAI prevention was included in the ARRA
funds. In a moment you will hear from Dr. Besser, my colleague,
who will discuss how $40,000,000 of these ARRA funds will be
spent to fund activities that support the Action Plan and
benefit the States.
The remaining $10,000,000 will be used by CMS to improve
the process and frequency of inspections of ambulatory surgical
centers. The ARRA funds allocated by CMS will allow States to
hire additional surveyors, which will increase the States'
capacity to maintain expected levels of ambulatory surgical
center inspections, while building a greater capacity to use an
improved survey tool nationwide.
HEALTHCARE-ASSOCIATED INFECTION PREVENTION IN A REFORMED HEALTH SYSTEM
The investment of ARRA funds in the fiscal year 2009
appropriations represents critical investments that we believe
show the value of how small investments can yield a large
health impact. The President has articulated that in order to
reform healthcare, prevention, healthcare quality, and patient
safety must also be priorities. Monitoring and preventing
healthcare-associated infections is fundamental to protecting
patients and improving healthcare quality. We at HHS are
committed to strong partnerships between Federal, State, and
local governments and communities to help prevent these
infections.
Thank you for the opportunity to testify today and, at the
appropriate time, I would be happy to answer any questions.
[The information follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Dr. Besser's Opening Statement
Mr. Obey. Dr. Besser.
Dr. Besser. Thank you. Good morning, Chairman Obey, Ranking
Member Tiahrt, and other distinguished members of the
Subcommittee. I am Richard Besser, Acting Director of the
Centers for Disease Control and Prevention, and it is my
pleasure to be here today to share with you CDC's plans for
utilizing the funds provided by Congress through the American
Recovery and Reinvestment Act of 2009 and the fiscal year 2009
Omnibus Appropriations regarding the prevention of healthcare-
associated infections.
I respectfully ask to have my written statement included
for the record.
Healthcare-associated infections are a serious and
pervasive public health concern. Mr. Chairman, as you noted,
these infections occur in all types of healthcare settings,
including hospitals, long-term care facilities, and ambulatory
surgical care facilities.
There are approximately 1.7 million healthcare-associated
infections, or HAIs, per year in U.S. hospitals alone, and they
are associated with 99,000 deaths. They have a tremendous
financial toll, resulting in an estimated $28 billion to $33
billion of excess healthcare costs per year.
Almost everyone knows someone who has been affected by
healthcare-associated infections. We have all heard stories of
a coworker, a friend, or a loved one who has entered the
healthcare system with one problem, only to acquire a life-
threatening, potentially preventable infection. Such stories
speak to the heart of the HAI problem.
The good news is that most of these infections are
preventable, and CDC has made significant progress in
developing effective prevention guidelines, tools, and
strategies. CDC is fully committed to achieving the national
goals and targets of the Department of Health and Human
Services Healthcare-Associated Infections Action Plan and will
continue to work collaboratively with our sister agencies to
assure our collective success. The funds provided in the
Recovery Act will supply much-needed investments to move toward
the elimination of these infections.
CDC plans to distribute approximately $40 million of these
funds dedicated to healthcare-associated infections, which will
be available to States, the District of Columbia, and Puerto
Rico. These investments will complement investments made by HHS
and the Agency for Healthcare Research and Quality, and will
ramp up State and local efforts to support prevention efforts
by doing three things:
First, creating or expanding State-based healthcare-
associated infection prevention collaboratives; they will
implement HHS recommendations and use CDC's National Healthcare
Safety Network system or standards to measure outcomes and
prevent these infections. These collaboratives will include
State hospital associations, Medicare quality improvement
organizations, and other partners, and will link to
complementary activities supported by AHRQ and CMS.
Second, enhancing State abilities to assess where these
infections are occurring and evaluate the impact of hospital-
based interventions in other healthcare settings.
And, third, building a public health workforce and health
departments with the knowledge base and expertise who can lead
Statewide initiatives to ensure progress towards the national
prevention targets outlined in the HHS Action Plan.
CDC will also use the Recovery Act funds to expand the use
of CDC's National Healthcare Safety Network and to enhance data
validation in States. The Safety Network is a secure Internet-
based surveillance system that provides a way to track,
analyze, and interpret data on healthcare-associated
infections. The Safety Network provides standard definitions
and protocols for tracking and reporting these infections. It
allows tracking of prevention practices and infections rates,
and it provides tools for data analysis.
Partially due to State legislation, participation in the
Safety Network has increased dramatically in the past few
years, from less than 500 in 2007 to presently over 2,200 U.S.
healthcare facilities in all 50 States. Demonstrating the
Network's success as a prevention tool, from 1997 to 2007,
participating hospitals have decreased bloodstream infections
by up to 50 percent.
CDC will use the Recovery Act funds to support new
activities in the State-based emerging infections program to
support targeted efforts to monitor and investigate the
changing epidemiology of these infections in populations as a
result of prevention collaboratives. As these collaboratives
move forward, the epidemiology of these infections will change.
Reporting through the Safety Network will provide a picture
of these infections in hospitals, and increasingly in long-term
care facilities and ambulatory surgical centers. Emerging
infections program findings will provide us with additional
insight into the impact of Recovery Act-funded prevention
activities, especially outside of the hospital setting.
In summary, the Recovery Act funds will be invested in
State efforts that support surveillance, improve healthcare
quality, encourage collaboration, train the workforce in HAI
prevention, and measure outcomes. Many of these funds will be
used to support activities outlined in the HHS Action Plan
which was released in January of 2009.
Based on the success that CDC and AHRQ have seen in local,
regional, and national initiatives, we anticipate a 10 percent
to 20 percent reduction in healthcare-associated infections
within two years of the successful implementation of the State-
based collaboratives.
CDC's 2009 Omnibus funds will complement Recovery Act
funding by expanding and enhancing the capabilities of the
Safety Network, as well as rapidly expanding efforts in States
to validate these data. This will enable CDC to improve the
Safety Network electronic reporting and thus reduce the burden
of data collection while increasing interoperability across
agency data systems.
In the future, electronic reporting will be a key component
of ensuring data validity and assessing the impact of HAI
prevention efforts in both hospital and outpatient settings.
CDC will also provide technical support for the National
Healthcare Safety Network implementation to all States.
In addition, CDC's injection safety funding will be used to
ensure that infection control measures are adhered to through
collaborations with the Centers for Medicare and Medicaid
services in support of their Recovery Act-funded activities in
outpatient settings that Dr. Wright just described.
The Recovery Act and Omnibus appropriations make
investments in healthcare-associated infection and prevention
and healthcare quality that form the foundation of a national
effort to improve the U.S. healthcare system. Small investments
made across States can yield a large impact by preventing
thousands of new infections in deaths and billions in
unnecessary costs for patients and the healthcare system.
We expect that with these investments, many more infections
will be prevented, many lives will be saved, and we will not
have as many sad stories to tell.
Thank you for holding this hearing on this important health
issue. I would be happy to answer any questions at the
appropriate time.
Mr. Obey. Thank you.
[The information follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Dr. Clancy's Opening Statement
Mr. Obey. Dr. Clancy.
Dr. Clancy. Mr. Chairman and members of the Committee, I
want to thank you for inviting me to this important hearing on
initiatives to improve and expand efforts to prevent altogether
healthcare-associated infections and ask that my entire
statement be made part of the record.
I would also like to building on Mr. Tiahrt's comments and
also add our congratulations to you on this important
anniversary and thank you for your service and leadership to
the Country.
AHRQ'S MISSION
AHRQ's mission is to improve the quality, safety,
efficiency, and effectiveness of healthcare for all Americans,
so we do this through research to improve the quality of
healthcare, reduce its costs, improve patient safety, and
address medical errors.
But a big, big focus for us is making sure that we can work
with hospitals, clinicians, and others to translate the
findings of research into practice and policy. So we are
thrilled and quite delighted to be working very closely with
our partners in HHS, particularly our partnership with CDC and
the Office of Public Health and Science, focused on reducing
and ultimately eliminating healthcare-associated infections.
Our mission at AHRQ is focusing on developing practical
scientific evidence-based information that clinicians and
healthcare organizations can use to improve care right now, and
this complements CDC's focus on public health and epidemiology.
Together, our investments will strengthen capacity in States
and local communities.
AHRQ's role also includes helping patients and doctors to
communicate better, so we have been working to encourage
patients to ask questions when they are in healthcare settings,
such as whether clinicians have washed their hands and have
offered them suggestions on how they might do that; it is not
such an easy thing to do. So I want to thank the Committee for
your continued support of AHRQ's investments in helping to
achieve this objective.
This is a very serious issue today. The infections do not
know any boundaries. They can affect people regardless of race,
gender, or socioeconomic status. So, therefore, the solutions
to this epidemic also have to break traditional healthcare
boundaries.
MRSA
One of the most common infections is MRSA, and I know that
this is well detailed in our written statements. Our data from
hospitals show that these infections have increased
dramatically in hospitals and that people with these infections
have longer hospital stays. In addition, our data from the same
hospitals is tracking the rapid emergence and rapid increase of
a new dangerous infection called Clostridium difficile. This is
alarming, to put it mildly. As you said, patients expect to go
into hospitals and get better, not come out with a second
problem.
PREVENTING INFECTIONS
The good news here is that these infections can be
prevented and dramatically reduced. AHRQ funded a research team
from Johns Hopkins University--and I know you will be hearing
from Dr. Pronovost in the second panel--that developed a
program designed to implement CDC recommendations to reduce
serious bloodstream infections in intensive care units. Known
as the Keystone Project, it reduced the rate of these
infections by two-thirds within three months in ICUs throughout
the State of Michigan. In addition, the average ICU reduced its
infection rate from 4 percent to close to zero. Over 18 months,
the program saved more than 1,500 lives and nearly
$200,000,000.
So how did this happen? Using a simple five-step checklist
designed to prevent certain hospital infections, and instilling
a change in how hospitals and clinicians view infection
prevention. Among other things, the checklist reminds doctors
to wash their hands and put on a sterile gown and gloves before
putting IV lines into their patients. One leader in critical
care medicine that I met said that this was the most important
development in his field in a generation. He said we knew about
these infections, of course, but we kind of thought they were
inevitable, that we could not do anything about them.
I am sure you are used to seeing doctors and nurses on TV
medical shows scrubbing their hands before surgery. Because of
this project, the practice is now routine in these intensive
care units as well.
So we are now funding an expanded project building on this
success and this project is being implemented across 10 States,
with at least 10 hospitals in each State to help prevent
infections related to the use of these central lines.
Thanks to your support and leadership, our fiscal year 2009
appropriation also gives us the opportunity to make this
initiative truly nationwide. AHRQ will expand our work in
reducing these central line bloodstream infections beyond the
10 States. We are going to expand the number of hospitals in
each participating State and increase the number of
participating States by an additional 20 States. And we will be
making sure that as our colleagues implement the funds in the
Recovery Act and we are working with State hospitals and
hospital associations so that our efforts are directed in such
a way as to build capacity in these States and local
communities.
The goal here is to reduce the average rate of central
line-associated blood infections in hospitals by at least 80
percent. But the ultimate goal, of course, is complete
eradication of these infections. We are also supporting five of
our ACTION partners to examine the barriers and challenges to
reducing HAIs at 34 hospitals. From this study we will be
developing a tool kit that healthcare organizations can use to
learn about how these projects and initiatives were
successfully implemented, the challenges that they faced, and
how they addressed them. Early results indicate that these 34
hospitals showed a 60 percent decrease in infections, and we
think that is only the beginning.
Mr. Chairman, we greatly appreciate the Committee's
understanding of the grave problem of HAIs and your foresight
in providing AHRQ with additional funds in fiscal year 2009,
and we will use the funds to invest in evidence-based research
to reduce the incidence of MRSA and other healthcare-associated
infections.
I am very pleased that the interagency workgroup that you
heard about from Dr. Wright has begun to develop potential
projects that build on our efforts in fiscal year 2009 and
address new high priority issues. These are also detailed in my
written statement.
Our funding in fiscal year 2009 will also help us address
infections, including urinary tract infections and surgical
site infections, as well as research on these infections in
other healthcare settings. Your chances of getting an infection
in a healthcare setting are not just limited to hospitals. So
we will be looking at units outside the ICU: dialysis centers,
nursing homes, and ambulatory care settings.
So, Mr. Chairman, thank you again for inviting me to
discuss AHRQ's efforts to improve and expand prevention of
healthcare-associated infections nationwide. We are committed
to continuing to work closely with our Department colleagues to
improve the quality of healthcare in our Nation and to ensure
that the public have access to the information they need to
make educated and informed decisions about their healthcare.
I look forward to answering any questions.
[The information follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Obey. Thank you very much.
Mr. Tiahrt.
PREVENTION CHECKLIST
Mr. Tiahrt. Thank you, Mr. Chairman.
Based on the testimony today, it sounds like it is very
simple. A five step plan? Can it be that simple? You know, 1.7
million people, 99,000 deaths, and it just boils down to not
washing your hands and a few other steps? This five-step
process, when you got the 60 percent reduction in these
hospitals, was that the inspiration of it or the methodology
used to achieve that?
Dr. Clancy. Five steps worked very, very well in intensive
care units. Like many things in life, the what to do is not so
hard; the how to do it is actually harder than rocket science.
The difficulty is getting everyone on the same page and
committed to consistently washing hands, sterile technique, and
also collecting data so that people can see the connection
between how they have changed their activities and the rate of
infections. They can see this. In the Keystone Project, people
got feedback quarterly. So this is not the quality department's
problem or the infection control department's problem, this is
our problem, and we have a role in fixing it.
In the other activities that we are funding that look in a
broader way across hospitals, one of the issues that they have
found is that there are overlooked aspects of breakdowns in
sterile technique. For example, in one institution, the
transportation folks were able to let the doctors and nurses
know that, once the patients go down to physical therapy, off
came the gloves, gowns, and so forth. So people upstairs were
working very, very hard at sterile technique and trying to
prevent spread of infection; they got downstairs for something
else, and all bets were off. So it is that kind of getting
everyone on the same page, because everyone has to be part of
the solution.
Mr. Tiahrt. I think the feedback is very good.
Dr. Besser, you mention in your written testimony that 27
States require hospitals to report HAIs publicly. How many
States require reporting but do not make it public?
Dr. Besser. Mr. Tiahrt, I do not have an answer to that
question. It is a moving target. Currently, of those States
that require reporting, 19 of them are using the National
Healthcare Safety Network, and we have more information on
those.
Mr. Tiahrt. Can you use a trend where they do report
publicly that they are more attentive to these common sense
practices to avoid infections?
Dr. Besser. I think what we see in general is that what you
measure drives change, and the goal of these programs is
quality improvement at the hospital level, at the patient
level, at the individual level. So the primary work that a
hospital is doing by being able to look at their data and
seeing where they have problems will drive implementation of
improved application of hospital infection control.
It is not rocket science. The principles that Dr. Clancy
was talking about, about sterile technique and hand washing,
are very simple. I served for five years as a pediatric
residency director. Getting students and residents to apply
these principles and do them in practice is the hard thing. So
simple things like checklists, which just seem so rudimentary,
can have dramatic impact.
Mr. Tiahrt. In your testimony you talked about how
everybody has had some kind of contact with someone. I have
experienced it myself, going into a hospital for a knee
operation and coming out with an infection. I had to stay a lot
longer. I know of other instances just recently. But is there a
risk? By requiring hospitals and other clinics and the whole
list that you have talked about, by requiring them to publicly
report this, does it put them in jeopardy of litigation, where
they become part of a lawsuit because somebody has a bad
experience like I did? Should we be concerned about that,
public reporting ending up in a court system where the hospital
or the physician or somebody gets sued over this reporting?
Dr. Besser. I think whenever a preventable bad outcome
occurs in a healthcare setting, there is risk of litigation.
But I think without awareness of the problem, it does not give
the institution or an individual the choice over where they
want to acquire their healthcare, and having that choice I
think is a major driver for change. I know that, personally, I
would want to go to a facility that had a lower rate of
infection than another.
Mr. Tiahrt. And so would I. I just think there is a
conflict here. We want the reporting. The reporting is
successful, it helps do the things we want to do to prevent
these from happening. Yet, it places an additional risk on
these facilities and physicians.
Thank you, Mr. Chairman.
Mr. Obey. Thank you.
Ms. Lee.
MRSA
Ms. Lee. Thank you very much, Mr. Chairman, and thank you
very much for this hearing, and welcome to all of you.
I guess as we age and as our family members age, we become
more acutely aware of what is taking place, and I, again,
personally, with a disabled sister and aging mother, have had
many, many experiences with this; and I would want to litigate,
let me tell you. And for those of you--and I probably know just
enough to not know enough, but let me just mention one incident
which confirms what you are saying as being, I think, a good
strategy.
A family member went into the hospital with a white cell
count of 10,000, normal; came out with a white cell count of
33,000, way up. Had to go right back into the hospital. Never
once did the hospital admit, or the physician admit, what had
taken place in terms of this infection having been developed in
the hospital. Everyone else knew it, but we could never get--I
knew it just by my elementary knowledge of what white cell
count, what is normal, what is abnormal, what transpired during
that 24-hour period. But you could never ever get the hospital
officials, the physicians, anyone to even raise that as a
possibility; and, as a result, we were trying to figure out
what, legitimately, we could do and what took place and never
got the correct answers, when we really knew what had happened.
So I do not mind the litigation round, really, if that has
to happen, but hopefully, with requiring the data to be
published, the scoring and what have you, that would help
hospitals step up to the plate and do what they need to do to
prevent these infections from happening.
I am concerned about the outreach efforts that are going to
take place in terms of them being culturally appropriate,
linguistically appropriate, because oftentimes African-
Americans, Latinos, Asian-Pacific-Americans, Native Americans,
we have to handle our outreach in an appropriate way so that
people understand what they are dealing with and what the
information really means based on their cultural background.
So I am asking you how do you plan to move forward on this
front and how, also, are you going to review the information
that you are proposing in your strategies with the minority
medical schools so that they too can incorporate this now into
some of their curriculum, if they have not already?
Thank you very much.
Dr. Besser. Thanks very much for the question. I will
address part of that and let my colleagues join in.
CDC is undertaking a campaign around MRSA, methicillin-
resistant Staphylococcus aureus infections. These have been in
the press a lot. These occur both in healthcare facilities and
in the community. So we have developed a lot of communication
materials, education materials, and in the development of
those, part of that is putting together focus groups from
different ethnic and minority group populations to make sure
that the messages that are in those will resonate.
One of the areas I think that we need to do more work in,
and we are thanks to the Committee and the resources in the
Recovery Act, is looking at healthcare-associated infections in
populations, so that we can get a better sense of what are the
different rates in various populations, where are there
disparities, and what is driving those disparities.
We know that African-Americans have higher rates of kidney
failure and diabetes, and that some of these infections are
associated with those conditions; and that the efforts that we
take to address the disparities that underlie those conditions
will help with the infections. But I think there is more to it
than that, and we need to understand are there particular
infections that we are seeing at disparate rates, and we need
to address that.
MALPRACTICE
Ms. Lee. And why will the hospitals not admit that this
infection occurred under their watch?
Dr. Besser. I do not know if you want to go for that one.
[Laughter.]
Dr. Clancy. Well, I think that is fear of liability. When
we have done work with doctors and patients, most patients say
that if they are harmed by healthcare--and this would be a
prime example--they want three things: they want an apology,
they want to know----
Ms. Lee. You are right, that is what we would like.
Dr. Clancy [continuing]. They want to know what happens to
me now----
Ms. Lee. Yes.
Dr. Clancy [continuing]. And, very importantly, they want
to know that the hospital or organization is going to learn
something and not do it again.
Ms. Lee. Yes.
Dr. Clancy. And doctors sure agree with them. They are
terrified of step one because of the potential for litigation.
Ms. Lee. Well, I will tell you one thing, they should be.
But we have to make sure that somehow, short of litigation,
that they know they have to clean their act up.
Dr. Wright. Congresswoman, let me say I share your concerns
about the outreach campaign and making sure that it is targeted
to the appropriate audiences. The outreach campaign will
actually occur within the Office of Public Health and Science,
and we intend to make every effort to make sure that we address
the appropriate communities. These messages will be tested for
effectiveness moving forward to address the concern you just
expressed.
Mr. Obey. Mr. Alexander.
Mr. Alexander. No questions.
Mr. Obey. Mr. Bonner.
HAI REDUCTION STRATEGIES
Mr. Bonner. Thank you, Mr. Chairman.
As we all know, Congress provided $50,000,000 in the
stimulus bill explicitly for States to implement healthcare-
associated infection reduction strategies. So I have got a few
questions I would love to get your knowledge to try to help me
understand.
It is our understanding, my understanding, that $40,000,000
of the $50,000,000 would be used by CDC to help States reduce
infections. In your written testimony, Dr. Besser, you
mentioned that the funds are being used for three purposes:
first, creating or expanding collaboratives that will implement
HHS recommendations; second, what appears to be enhanced
surveillance capability; and, third, what looks to be a subsidy
for State health departments to hire additional employees.
So my first question is how much of that $40,000,000 do you
expect would be spent in each of these three areas?
Dr. Besser. We are still working through the finalization
of the spend plan for this, but each of those components is a
critical part of the equation. The collaboratives are
absolutely essential because they pull all the players together
who have a stake in this, both a stake in improving, but also
have the ability to work with their members and with the
medical community to address those issues.
Healthcare-associated infections is one of those areas that
State health departments have not had many resources to support
for a long time, so being able to support this at the State
level will allow them to look at data within their State and
identify where the problems are, and have individuals who are
focused on that and focused on working on solutions. So both of
those components are very important.
The other piece of looking at these infections in
communities is important because there will be changes in how
these infections are occurring by the very efforts we do to
prevent them in healthcare settings. One example is the issue
around methicillin-resistant Staphylococcus aureus, where this
was a problem that we initially saw almost exclusively as a
problem in healthcare facilities. Then, over time, we saw this
in the community. And it was the work done in these
surveillance systems that let us really understand that these
were related problems, but had very different epidemiology and
very different control strategies.
So the vast bulk of the money is going to the States and
the coalitions for the implementation of what we know are
evidence-based strategies that work.
Mr. Bonner. Well, how much does it cost a hospital or a
State to report infection data to the National Healthcare
Safety Network, and what percentage of hospitals currently
participate in HSN?
Dr. Besser. NHSN, we have been very pleased by the dramatic
increase in its use over the past couple of years, from a few
hundred to over 2,000. A third of all hospitals are now
participating in that system. And what we are seeing is that
the standards that are in NHSN are used by additional
hospitals.
Our goal is the reporting, not the system. We are really
pleased that many hospitals find this to be a very useful
system for reporting. We do not charge hospitals anything to
use this system, and, thanks to the Committee and the 2009
appropriations, we are going to be able to provide additional
technical support to States so that there can be training, we
can make improvements to the system, because we do hear from
some hospitals about difficulty in data entry and problems with
our servers. We are going to be upgrading those systems.
So the resources that are coming from the Recovery Act and
the resources that are coming through the Omnibus appropriation
will synergistically help build a system that is really
focusing on these preventable infections.
Mr. Bonner. And that leads to my last question. If I am
correct on the workforce issue, has any thought been put into
how the States will sustain these new employees if and when
Federal funding for HAIs ends?
Dr. Besser. Well, one of the requirements is that all
States submit a plan on healthcare-associated infections by
January of 2010, and one of the components of that is looking
at sustainability. What I expect States will see, States who
take this seriously and implement this, is that they are going
to see cost savings in terms of the added burden to their
healthcare system and their healthcare dollars from treating
infections that were preventable. And hopefully that will lead
to States seeing the benefit in providing support for these
personnel.
Mr. Bonner. Thank you, Chairman.
Mr. Obey. Thank you.
Ms. Roybal-Allard.
OUTREACH CAMPAIGN
Ms. Roybal-Allard. Thank you, Mr. Chairman, and thank you
for having a hearing on this truly critical issue.
When we are talking about this issue, sometimes I cannot
believe what I hear. You know, when you talk to parents
sometimes, they say, well, I try and get my children to wash
their hands, but I cannot always get them to do that. I am
trying to get them to eat their vegetables, but we cannot. But
we are talking about children.
In this case we are talking about health professionals who
supposedly their primary goal is the care of patients. Just in
the last few months, I have had, in hospitals and a friend, a
newborn baby die of respiratory infection in the neonatal unit
because of an infection, an adult died of cardiac arrest
because they forget to put his heart monitor on, and the best
friend of my daughter just died here, he was a U.S. marshal,
because they released him from the hospital with staph
infection and went into a coma at his home.
And what I am hearing is, gee, this is a good thing to do,
but we cannot get the students to do it and we cannot get the
doctors to do it. To me, it is absolutely incomprehensible and
there has to be some penalty. It is not good enough just to
say, gee, we would like to get them and we hope that this
happens.
Which leads me to my question. While I do think it is
important to empower families and individuals, the reality is--
and I spent months in the hospital with my mother and my
father--the reality is that not every family can do what my
family did and stay 24 hours and alternate every night. And we
were not other to keep either my mother or my father company;
we were there to protect them from my mother being wheeled out
to have some procedure, operation done for which it was the
wrong patient, and I could just go through a whole list of
things.
So I agree that it is important to help to empower the
public, but also I believe the primary responsibility to ensure
an infection-free environment starts with the healthcare
providers themselves.
So given the high costs associated with the national
campaign, would not the money be better spent in educating and
ensuring that physicians and healthcare providers are following
the infection control guidelines, and put the focus on that,
while at the same time there are other less expensive ways--and
I am sure that members of Congress would be more than happy to
assist in getting that information out to our constituents--and
use those resources that you have to do whatever is necessary
to get the health profession to do what they are supposed to do
and make the care of their patients and their well-being the
priority?
Dr. Wright. Congresswoman, I agree and I share your
concern. I will say that, as part of the outreach and messaging
program, I mentioned that we were going to try to educate
consumers, and we are. But that is not our only audience.
Clearly, healthcare institutions have a big role in solving
this problem, as well as health providers, and we will have an
outreach strategy targeting those two groups as well.
A particular focus group that we think will also be a focus
group of this outreach campaign are paraprofessional schools--
medical schools, nursing schools and ancillary health schools.
It must be in the curriculum of these schools--good infection
control practices--so that we can create a culture of safety
that will follow healthcare providers as they go through the
next 20 or 30 years of their careers.
We do want to address both healthcare institutions and
healthcare providers going forward.
Ms. Roybal-Allard. Well, I guess my point is that I do not
think that it should be optional and we should not be hoping
that they do this. There has to be a way that it is required
and that there is a penalty to pay if they do not. And if it
means that, as Congresswoman Lee said, litigation, then so be
it.
Dr. Clancy. The only thing I would add is I definitely
agree with everything that you had to say. I think most of us,
for ourselves and our family members, parents, whatever, would
want to know ahead of time what hospital--particularly for
elective admissions, where you are going to have a procedure or
surgery or something--which hospitals are doing a better job. I
do not think that is too much to ask, until we get to a place
where they are all doing a superb job.
Ms. Roybal-Allard. I agree, and that is why I am concerned,
if I understand it correctly, that it is voluntary to report.
So, therefore, how do you get an accurate picture of the
various hospitals when everything is voluntary. And given the
concerns that were raised about litigation and other things,
you really are not going to have a clear picture, and it could
be very misleading to the public to think, by looking at that
list, they are getting the right information.
Mr. Obey. Mr. Tiahrt.
INFECTION TOOL KIT
Mr. Tiahrt. Dr. Clancy, you mentioned a tool kit that had
some success or great success in, was it hospital ICUs?
Dr. Clancy. No, this was hospitals more broadly.
Mr. Tiahrt. More broadly?
Dr. Clancy. Looking at methicillin-resistant Staphylococcus
aureus.
Mr. Tiahrt. Could you just give me a brief idea what is in
the tool kit, because I picture a metal box.
Dr. Clancy. No, and we may need a better word than that.
Some of it is actually just decision support so that they can
remind folks about what they need to do for those hospitals
that already have electronic health records. Some of this work
is coming out of Indianapolis, where they are well ahead of the
rest of the Country in terms of not just having electronic
health records, but actually being able to share information
across hospitals.
Some of the tool kit that they use in Indianapolis, which
is probably only suitable for them, is that if you have been in
one hospital, go home and are then readmitted, when you go to
the second hospital, you are automatically identified if you
have had one of these infections before. Whereas, today, that
would depend on the patient or a piece of paper following the
patient.
Some of the other elements of the tool kit are protocols
for getting all the members of the healthcare team and making
it very clear who is the healthcare team, including people
transporting patients and so forth, as well as a very succinct
summary of what has worked for them and how they had to
customize from national guidelines.
Mr. Tiahrt. Thank you. I have a much better idea now.
Mr. Obey. Ms. McCollum.
INFECTIONS
Ms. McCollum. Thank you, Mr. Chair. I had the privilege of
having an appointment by the Speaker to be on Government Reform
last year, so we had several hearings on this, and I am pleased
that we are moving forward, because we have identified that
there is a problem. Sometimes everybody has to admit there is a
problem. And the funding in the recovery package--and I would
like for you to elaborate on this a little more--can be one-
time funding to help do the computer patches so that your
system and another system can talk to each other so we can
collect data.
And coming together and collecting data to provide best
practices is really important. I guess I am entitled to a few
boasting rights with Hubert Humphrey's quote on the wall here,
but Minnesota, when I was in the State House on health and
human services, we started talking long and hard in getting
everybody on board to see this as not threatening, not as
litigation. It took a while to get everybody there, but we
worked on developing what is in the best interest of the
patient, the doctor, the hospital, everyone.
So, in 2003, Minnesota was the first State in the Nation to
pass a mandatory adverse health event reporting law, and it
took us a while, in my opinion it took too long to get there,
but we did get there, and people were gearing up and getting
ready for it. So we do have some best practices out there.
There are 23 other States that have some best practices models
out there.
What we found now is that Minnesota now, according to our
hospital association, ranks first in the Nation of overall
healthcare quality performance indicators, and what we are
talking about today in preventing infections from happening, is
one of those performance indicators.
So what you are kind of looking at doing--to go back to the
toolbox analogy--you have got some tools in the toolbox and now
you are ready to take them out and show them to other States.
And when you do this right, it does not necessarily mean
litigation, but what it does mean, is that if you have the
information in front of you, if you have had the check sheet
and if you have not followed it, people in perhaps an operating
room, are now bound to report that it was not followed. It is
going to make it much easier for someone to litigate a case
because everybody has been aware of what is supposed to happen,
and it better not be happening; and if it does, people will be
held accountable.
And it goes as far as--if we had a different outcome. A
dear friend had a baby on Christmas Day, and when I went in, it
was at a hospital where my kids had been born too, and when I
walked in, I knew I needed to wash my hands and everything, but
posted up above it was, as you are washing your hands, please
sing to the baby Twinkle Twinkle Little Star, so that you are
washing your hands and rinsing them long enough. And it also
had it available in Mong and Spanish, multi-language.
So there are best practices out there. So could you maybe
elaborate on how you are going to take these tools that you
have in your toolbox and take them out there?
Dr. Besser. I think that the story you tell there about a
promising practice in Minnesota is just a great example of what
we expect to come out of this recovery funding. The idea that
all States are now going to be working on this, many States
that had not been addressing issues of healthcare-associated
infections before. We are going to see innovation. We are going
to see creative ideas. We are going to see promising practices
come out of that. And in our roles within the Department, we
are going to be able to capture those and share those ideas.
The point you made about measurement driving accountability
is just right on target. Without measuring what is going on in
a hospital, without bringing it to light, there is no way to
hold individual clinicians accountable for what is taking
place; there is no way that citizens are able to have choice
between where they are seeking healthcare, and that will drive
change.
I ran CDC's program on Legionnaires' disease for a number
of years and we faced this same issue around Legionnaires'
disease, that if you detect a case, it is going to drive a
lawsuit. Well, if you are not addressing this issue and looking
at prevention as a medical institution, yes, you are going to
get a lawsuit. But if you are taking this on and you are doing
what has been known to be done as evidence-based practice, and
there is still an infection that takes place, you are in much
better shape than if you had not been addressing this problem
in the first place.
Dr. Wright. Congresswoman, I wanted to also point out that
we do believe that the inspection process provides a potent
deterrent on these lapses in infection control practices. The
$10 million in ARRA funds is directed to that effort, to
increase the survey process of these ambulatory surgical
centers that have had high rates of infections to make sure
that we can drive those rates down through the survey process
moving forward.
INFECTION CONTROL TRAINING IN CURRICULUMS
Mr. Obey. Let me just make an observation. I do not want to
take a lot of time because we have another panel, but, as I
understand the numbers, 99 thousand people died from these
infections last year, in comparison to, I believe, 14 thousand
who died from AIDS last year in this Country. If those numbers
are correct, that, to me, is astounding, because we have
tremendous public attention paid to diseases like AIDS or
cancer. Yet, we have six times as many people dying from
something that ought to be much more easily correctable because
at least we know, in most instances, what causes the problem
and how to correct it.
We do not know the answer to dealing with diabetes or
Parkinson's. We are spending a hell of a lot of money on that.
It seems to me, for a very little bit of money we could have a
tremendous increase in the quality of public health.
We have got a lot of talk about markets and how we should
let the markets work. It seems to me the best way to make the
market work in this situation is to make doggone sure that
every single patient who walks into a hospital knows what the
relative infection rates are in the hospital that he or she is
considering entering. If they know that, it means that the good
old market is going to work, because they are not going to go
to the hospital that has a lousy infection rate if they know
about it.
Second thing is that, to me, in addition to having the
patient know this information, the press is going to know it if
you get it out there enough, and the press will raise enough
cane. That creates additional pressure to fix the problem. That
is part of the market too.
I guess, in the end, the one place where I think we are on
very weak ground is in relying on patients to ask the
professionals to do what they ought to be doing. When you are a
patient, you are intimidated by the people who are taking care
of you; you do not want to antagonize the physician who is
taking care of you because you want him to like you and care
about you. So I think it is awfully tough to expect that the
patient is going to blow the whistle and say, hey, did you
change your gown.
I mean, what is the process by which an average doctor or
another provider in any hospital gets the information today
about how to do to avoid this avoidable problem?
Dr. Wright. Well, certainly, I think good infection control
practices are part of their curriculum, whether they are in
medical school or nursing school, and we are going to target
that area to make sure that those curriculums are enhanced.
CHECKLIST
But like other human behaviors, there needs to be
reminders, and as one of the congressmen mentioned, there needs
to be reminders to doctors, such as checklists, on an ongoing
basis about the importance of hand washing. The checklist was
basically a reminder of what the CDC had said for years was how
you correctly insert a catheter to prevent infection, and yet
it was this checklist that made sure that that occurred each
and every time, and we can see what the dramatic result of a
checklist of that nature actually did.
So I think it has to be a multi-pronged approach to
ensuring that healthcare providers use good infection control
practices.
Dr. Besser. To add to that, I think that informing
consumers is part, in terms of choice, but I think that your
comments about the power relationship between a healthcare
provider and a patient is on target. I started a program at CDC
on appropriate antibiotic use, and promoting the use of
antibiotics only where indicated; and was in on a focus group
and people were asked, well, do antibiotics work for colds or
they work for ear infections, or both, and half the people said
both. Then they were told, well, they only work for bacterial
infections, and one of the people in the focus group said, I
cannot believe that, last week my doctor gave me an antibiotic
for a cold, I am furious. We said, well, are you going to say
anything to him? And it was like, oh no, I am not going to
question my doctor.
So informing patients is part of it, but I think you are
right on target that we need to work with the medical
community. We have to ensure that the system is built to get
these out of it. And making this information available, making
an impact on the hospitals' bottom line, because they are going
to see an impact on the bottom line if they are the worst
hospital in their community in terms of infection rates; that
is going to drive change. Each of these pieces is important,
but there is not one that is the magic bullet.
Dr. Clancy. So I guess I would just add to that. You know,
I was in Ireland a couple years ago for a conference, and I
was----
AWARENESS ABOUT INFECTIONS
Mr. Obey. What is somebody named Clancy doing in Ireland?
[Laughter.]
Dr. Clancy. That is right. Amazing.
I was amazed that infection rates for all hospitals in the
country, Ireland, are tracking infections that we are not
keeping as close an eye on. They were all over the newspapers
every single day. I want to say a little over 90 percent of the
hospitals reported, and those that declined the opportunity
were dutifully noted by the press.
I am not sure we can count on that as a full-time strategy
here, but I think it helps.
And, I agree with everything you said about patients.
In terms of what students and residents learn, everybody
learns about epidemiology and washing hands. What we have not
valued in healthcare until recently is the notion that we are
going to get it right every single time. So we learn about hand
washing and infections so we can pass a test. What we do not
get is the part that says if you do not own this and wash your
hands every single time, then you will actually be creating
infections. It is the not owning up to it that Representative
Lee talked about.
So we are getting better on that in healthcare now. We are
starting to focus more on reliability or doing the right thing
every single time, but we still have a long way to go.
FINANCIAL INCENTIVES
Mr. Obey. One last question. Financial incentives often are
incentives. Beyond the positive incentive of a bonus payment
for voluntary reporting, should we be considering moving to a
value-based performance measuring system where a portion of a
hospital's payment would depend on actual performance,
including infection rates?
Dr. Clancy. CMS is doing a little bit of this now by not
paying for the extra expense incurred by some types of
infections that are largely preventable. In the aggregate it
will not save that much money. What it does do is it sends a
very powerful signal to the green eyeshade guys, the chief
financial officers and so forth at hospitals, that this
matters.
So when your colleague asked how much does it cost
hospitals to participate in NHSN, that depends how you look at
it. They do not have to pay CDC, but they actually have to hire
people and make sure that they are trained and have the time to
do it.
So I think it is a powerful signal. It is not going to be
transformative until we build more capacity and know-how within
hospitals. I think the good news is hospitals want to go there
too, but right now, if you set the bar too high, a lot of
hospitals would not be able to do it; they simply do not have
the infrastructure.
Mr. Obey. All right, thank you.
Any other questions for this panel before we move to the
next one?
Ms. Lee. Mr. Chairman, one more, please.
Mr. Obey. One question, sure.
Ms. Lee. Okay, one more questions. Assuming that what you
are proposing is enacted, what if there is no option? Public
hospital, for example. What if the rating on infections is so
low the people do not have an option, they have to go to the
hospital, first of all? Secondly, an ambulance is going to take
you to the closest hospital where there is an emergency room
whether the rating is high or low. So how do you factor these
concerns in to an overall rating system where the public knows?
Because oftentimes you cannot say where the ambulance is going
to take you, and if you are a victim of a gunshot wound, you
are going to go to the closest trauma unit, whether the
infection rates are high or low.
Finally, just with regard to the infrastructure, the nurse
shortage, physician shortage, how does that play into this, if
it plays into this at all?
Dr. Clancy. Right. The last thing I think anyone wants--and
I am very worried about this--is to simply give more rewards to
those hospitals that are already doing a good job and actually
make it worse for those who actually do need more of a boost.
There are a variety of technical strategies to deal with
that, that is to say, rewarding based on achieving a certain
level of performance, as well as rewarding improvement. I would
be happy to follow up with you on that.
[The information follows:]
Technical Strategies
Dr. Clancy: Strategies to assist institutions with fewer resources
might include: (1) ``pay for improvement,'' where institutions are
provided with financial rewards for improvement from a base level--even
if low--as opposed to getting rewarded only for reaching a threshold
level of performance; (2) ``pay for participation,'' where institutions
that may have trouble affording needed changes are given partial
support as an incentive to participate; and (3) direct technical
assistance on how to implement best practices. This could be achieved
through AHRQ support for learning networks or partnerships, or targeted
assistance from a quality improvement organization.
Dr. Besser. I wanted to add to that. Recently, I have been
asked by a number of people if there is universal access to
care, why do we need public health. What is the value of public
health if people can get to see their doctor? And I think that
your question points specifically to an important role for
public health.
Public health is there to assure that that a public
hospital is not allowed to have standards that are worse than
anything else. Public health is there to be able to go in and
look at what is driving those issues of increased rates of
infections or worse quality. And the resources that you have
provided will allow States to fulfill that function, and it is
a critically important function so that we do not end up with a
two-tiered system of healthcare.
TRANSPARENCY
Dr. Wright. Congresswoman, I want to make just one point
and you are right on target. We do believe in transparency in
healthcare, and that healthcare consumers need to be provided
as much information as possible to make an informed decision of
where they get care. This is very applicable in a large city
such as Washington, DC, where there are multiple choices.
For rural America, there may only be one hospital in that
area and the choice is much more limited, and that is the
reason I agree with Dr. Besser that, for us to move forward, it
is going to have to be a multi-pronged approach. There is no
single bullet. All of these will contribute in a positive way,
but there is no single answer to this problem.
Ms. Lee. Well, thank you very much, Mr. Chairman. I still
say litigation still has to be on the table.
Mr. Obey. Ms. Roybal-Allard, you had a question?
Ms. Roybal-Allard. Yes.
Dr. Besser, my question has to do more with the ability to
treat the infections after they occur. Some of the most deadly
healthcare-associated infections are resistant to multi
antibiotics. In fact, the Steering Committee has recommended
research to prevent unnecessary antibiotic use.
I would like to point out that 70 percent of antibiotics
used in the United States are used by farmers, and many
scientists believe that the farming practice of buying
antibiotics and feeding them to healthy cows and pigs
contributes to this antibiotic resistance.
How does this overuse of antibiotics in agriculture
contribute to drug-resistant infections in humans, and what
should be done to address this overuse?
Dr. Besser. Congresswoman, thank you for that question. The
issue of antibiotic or antimicrobial resistance is a major
public health problem, and it occurs for many different
factors. It occurs because of overuse of antibiotics in people.
We know that the use of antibiotics on the agricultural side
drives resistance in strains that we see in animals, and that
some of those strains then cause infections in humans.
But this is a big problem. It is a big problem not only
because we are seeing a rise in resistance, but we are not
seeing the development of new drugs that can be used to treat
these infections. In the healthcare setting there are a number
of strains of bacteria where we are reaching the end of the
line; we are absolutely running out of drugs that will be able
to treat them.
So I think you raise a very important issue. We need to
look at the use of antibiotics in agriculture. And countries
differ greatly in terms of their standards of what is allowed
to be used on the farm, and we need to look at how antibiotics
are used in this Country, both in the healthcare setting and in
the outpatient setting, because they are all factors driving
resistance.
Ms. Roybal-Allard. And whose responsibility is that to
actually do that kind of study and research?
Dr. Besser. I think that there are pieces of this that fall
to different parts of government. At CDC, we have a campaign
called Get Smart: Know When Antibiotics Work, which I founded
about eight years ago, and that is directed at reducing the
overuse of antibiotics in the outpatient setting. Our Division
of Healthcare Quality Promotion does a lot of work on
appropriate antibiotic use in healthcare settings, and we have
a group at CDC on the food side that does studies to look at
the development of resistance in animals and the transmission
of those strains to humans.
A number of years ago there was a transfederal task force
that was put together to address antimicrobial resistance that
brought people in from across government to address these
issues and develop an action plan. There was a lot of progress
made on that action plan, but there is so much more work that
needs to be done to address those issues.
Ms. Roybal-Allard. Okay, but there is no directed effort to
reduce this right now. Sort of what you are trying to do with
hospitals.
Dr. Besser. Well, there is work being done at FDA and USDA
on the animal side, and I need to refer you to those groups to
get details on those activities.
Ms. Roybal-Allard. Thank you. I appreciate that.
Mr. Obey. All right. Let me thank the panel. I appreciate
your time.
Next, we will ask our second panel to come forward: Dr.
Peter Pronovost, Professor, Department of Anesthesiology and
Critical Care Medicine and Director, Quality and Safety
Research Group at Johns Hopkins; Ms. Rachel Stricof, Director
of the Hospital-Acquired Infection Reporting Program, New York
State Department of Health; and Dr. Robert Hyzy, Associate
Professor of Internal Medicine, Division of Pulmonary &
Critical Care Medicine, University of Michigan Health System.
Thank you all for coming. Dr. Pronovost, why do you not
begin?
----------
PATHWAY TO HEALTH REFORM: IMPLEMENTING THE NATIONAL STRATEGY TO REDUCE
HEALTHCARE-ASSOCIATED INFECTIONS
WITNESSES
PANEL 2: OUTSIDE EXPERTS
DR. PETER PRONOVOST, PROFESSOR, DEPARTMENT OF ANESTHESIOLOGY AND
CRITICAL CARE MEDICINE AND DIRECTOR, QUALITY AND SAFETY RESEARCH
GROUP, JOHNS HOPKINS UNIVERSITY SCHOOL OF MEDICINE
RACHEL STRICOF, DIRECTOR OF THE HOSPITAL-ACQUIRED INFECTION REPORTING
PROGRAM, NEW YORK STATE DEPARTMENT OF HEALTH
DR. ROBERT HYZY, ASSOCIATE PROFESSOR OF INTERNAL MEDICINE, DIVISION OF
PULMONARY & CRITICAL CARE MEDICINE, UNIVERSITY OF MICHIGAN HEALTH
SYSTEM
Dr. Pronovost's Opening Statement
Dr. Pronovost. Thank you, Mr. Chairman. Given my family
spent this summer visiting some of our national parks, I am
indebted to your service.
Congressman Tiahrt, Congresswoman Lee, and Congresswoman
Roybal-Allard, the healthcare systems ought to provide you
better care than you receive. It ought to provide many of us
better care, and, as a provider, I apologize for the care that
you received at our U.S. healthcare system.
The outrage that you express, or the incredularity about
addressing these problems are well deserved. What I would like
to do is think through the science of how we might get a better
solution, and I would like you to imagine that there is a new
deadly disease in this Country, a disease that kills 100,000
people a year, and some researchers at Johns Hopkins tinkered
around and found a cure. They then worked with funding from the
Agency for Healthcare Research and Quality and implemented that
therapy in the entire State of Michigan and virtually
eliminated the deaths from this disease, this once thought to
be incurable disease.
If that word spread nationally, that would save more lives
than virtually any other therapy in the last quarter century.
Indeed, this 100,000 lives makes it about the fourth leading
cause of death in this Country.
And if that therapy were a drug or device, it would be in
every one of the hospitals in your States within months,
probably. The market would respond. People would produce it,
the cost would come down, lives would be saved, jobs would be
created, and it would work.
And, yet, this disease is real. The disease is deadly and
it is costly. And I can assure you the inventor of this therapy
did not get wealthy; the market did not respond. And I think
because the therapy is not some drug or device, it is a safety
program. It is a safety program that has three key components
to it: a summarizing evidence into a simple checklist, a valid
measurement system based on CDC definitions to know whether we
are making progress, and tools and strategies to improve
teamwork, frankly, to get doctors and nurses to work
collaboratively towards a common goal.
And to develop that, we approached it with the same
scientific rigor that you would drug develop. In the first
phase, Johns Hopkins was our learning lab and we sought how to
summarize the evidence using much of what CDC put together on
how to measure these. We then tried to, in phase two, apply it
in a whole State; and you heard the results were almost
breathtaking, somewhere around 2,000 lives saved a year,
$200,000,000 saved, virtually eliminated two of the main types
of this infection, cath-related infections and pneumonias, all
with a $900,000 investment from the Federal Government.
In the third phase, now, we are finally, several years
later, working to scale this nationally. We are fortunately
coordinated under HHS to have funding from ARC to put this in
10 more States, working with the CDC to measure and summarize
the evidence, and I believe what we have in this is truly a
national model; because there are many woes that befall our
healthcare system. It just, frankly, is not performing up to
par.
But the reality is we do not have the equivalent of a polio
campaign. We have not licked one of the problems, and we need
to learn how to do it, and I think this provides a model,
because what we saw is that debate about whether you should
take a regulatory or a free market approach is a false choice,
I think. It is neither efficient nor effective for every
hospital to summarize the evidence or to develop their own
measures; they ought to be centralized under our experts in the
Federal Government.
Yet, at the same time, we need to have creativity and
innovation of how to improve and implement that evidence. So
there needs to be all the stakeholders involved in. Yes, we
need the courage to set national goals. Yes, we need clarity
about what the strategy is. And, yes, we need commitment to
deliver that strategy. But it has to pull as many levers.
Payment policy is part of the levers, science coordinated
centrally is part of the levers, but so is coordinating
hospitals with the States.
What I think is most informative is to think for us why has
not this lifesaving therapy--literally, that would be the
innovation of the last quarter century spread. And I think
there are two reasons why it has not spread that can inform us.
One is because these deaths are invisible. They are opaque and
the public does not know about them. You do not know about
them, for the most part. After a GAO hearing, Congressman
Waxman surveyed States, and 11 States monitored these
infections right at the time. As you heard from Dr. Besser, it
is many more now.
But all the States said they are using the checklist, and
yet none of those States where infections were anywhere near as
close to as low as what Michigan was, and that is, I think,
unacceptable. If these rates were transparent, people would
respond; hospitals would compete, and we would see things down.
The second lesson why I think the market did not respond or
why we did not spread this is this is really hard work, and it
is naive to think that handing docs a piece of paper will do
it. There is science to this, science of behavior change,
science of measurement; and we have been woefully inadequate in
our investment of those sciences.
Yes, Mr. Obey, there are about six times more people who
die of these infections a year than do AIDS. And, yet, we spend
$2,600,000,000 on AIDS research. The entire budget for AHRQ is
$300,000,000. We spend 14-fold more on one disease than we do
for all of these learning how to improve quality, and
healthcare infections are but one of the many preventable
causes. We do not know what the true estimates are, but if we
looked at all preventable harm, it would undoubtedly be about
the third leading cause of death in this Country, and the
investment has not been commensurate, because, yes, we can get
outraged and say why is this not happening, and that is needed
and we need malpractice reform, we need payment reform.
All of those have to be part of the levers. But they are
all incomplete. We have to invest in the science of this. That
is what we did in Michigan. But there is no pipeline to say,
well, who is funding the next program to do catheter infections
or to prevent blood clots, because there has not been that
commensurate investment.
So where I think we could go is I believe, and it is
exciting to see, that we may use some funds to say this
bloodstream program ought to be a national program, and not
just save the 30,000 to 62,000 lives that die from these
infections, but learn how to work together and build capacity
to tackle the next ill that befalls us.
I think we need much more clarity in regulation about what
quality data is reported. If you look at what hospitals put on
their websites, it is far more marketing than science. You can
click now and hospitals will say we have no infections, without
saying which ones or for how long. You have private agencies
rating hospitals that you can look in any State and you would
find a hospital who makes it on somebody's top 10 list; and
none of the three big--U.S. News & World Report, which we
happen to be on, J.D. Power's or Health Grades--none of the
same hospitals are on their top 20 list. How could that be if
they are actually measuring quality? The reason is because
there is no standards.
So I would encourage you to do what Franklin Delano
Roosevelt did in 1934, when he created the Securities &
Exchange Commission, is ensure that the data that is reported
about healthcare quality is accurate in this Country.
I think it would be unwise to regulate ``the use of this
checklist,'' because just this list, in a major medical
journal, a new technology came out that I will be speaking to
Dr. Clancy and Dr. Besser about maybe adding to our checklist.
And regulation, I think, is too slow to allow that innovation
to occur.
But we ought to have confidence that you can select a
hospital based on what these rates of infections are, and I
think we need to invest substantially more in the science of
healthcare delivery. If you look at what we did with the human
genome, with your graciousness, we now sequenced, through a
public-private partnership, all 3.2 billion letters in the
human genome with 99.9 percent accuracy. It took us 15 years,
but we now are using that to discover new drugs and therapy.
We have not had the same kind of investment in the delivery
of healthcare, and we need the human genome project in
healthcare to create an institute that coordinates these
efforts, that advances the science and learns how to do it, and
that trains clinicians, public health professionals, and
researchers to learn how to do this.
I thank you.
Mr. Obey. Thank you.
[The information follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Ms. Stricof's Opening Statement
Ms. Stricof. Hi. Chairman Obey, Ranking Member Mr. Tiahrt,
and the rest of the Subcommittee members that are still here,
my name is Rachel Stricof, and I am very thankful to be able to
be here today. I am the Director of the Healthcare-Associated
Infections Program for the New York State Department of Health.
Within our program, we do have healthcare-associated
infection reporting and also outbreak investigation and
guideline development. But we are a unique State in that there
are some dedicated resources for these efforts.
Just to give you a little background, in July 2005,
legislation was passed requiring hospitals in New York State to
report select hospital-acquired infections to the Department of
Health. Our legislation had some unique features that may be
different than other States, and I think some of those were
very important in being able to really evaluate the data that
we are seeing and to be able to use it.
First of all, it gave us flexibility to decide what kind of
reporting system we wanted and whether to use existing data or
the National Healthcare Safety Network or our own. It provided
us time to implement the reporting system in such a way that we
could train the hospitals and we could truly standardize the
way they were interpreting definitions, the way they were
conducting their surveillance so that we would not be
penalizing hospitals that had better surveillance systems and
therefore were reporting higher infection rates.
It also gave us the authority and ability to conduct audits
in the hospitals to determine whether the reporting that we
were seeing was accurate and reliable or not. It gave us the
ability to consult with technical advisors and to be able to
modify the system before we started collecting data that would
actually be hospital-identified data that would go to the
public. It also provided for grants for infection prevention
and control collaboratives as a result, not only as a result of
our legislation, but related to healthcare-associated
infections.
So our first challenge was really to say--and I know this
is still a struggle at the national level--how are we going to
report these infections. And at the time we were doing this, we
were the seventh State to have legislation; none at the time
had enrolled in the NHSN or actually selected the NHSN for
reporting purposes, so we were the first State to do that.
And I have to mention that this was really a challenge
because there was a lot of pressure on us as a department to do
one of two things: it was either to use an already existing
data set, basically the hospital administrative data for
billing purposes, and say you can use that data to really
determine hospitals' infections rates. There was a lot of
pressure to do that because it was an existing data set, it
would not cost additional money, it would not take additional
resources from the hospitals.
The trouble is, for decades, we have been evaluating that
data source and have found it to be very unreliable when it
came to the actual infection rates that they were reporting,
because that system was not developed to determine what you
acquire in the hospital versus what came in from the community.
Then we had another challenge even within our own
department, because some of you may know that New York likes to
do things their own way and likes to be totally in control. So
we looked at whether we should develop our own unique data
system or whether we should go with the National Healthcare
Safety Network.
I will tell you we ended up taking nine months, almost as
long as to have a baby, to make this decision. Well, about the
same. There were many reasons that went into this, and I think
it is important for you who are going to be decision-makers as
to how we implement this to hear some of our reasons as to why
we picked the NHSN.
One, it was recognized and respected worldwide; two,
hospitals said that they were using the CDC criteria for
measuring infections, but as we all know, if all of a sudden
that information is going to be made public, all those
infections get open to a lot of interpretation unless those
definitions are truly standardized and the interpretation of
the definitions are standardized.
Ten percent of our hospitals were already using the NHSN.
We had another 10 percent of sister facilities that were
waiting to use it and another 5 percent of facilities that were
on a waiting list to use it. So we knew there was interest in
the hospital community to use it as well.
It did have, again, the standard definitions, surveillance
methods, and risk adjustment to make the rates more comparable
between hospitals if you were going to compare infection rates.
There were considerations into how to risk adjust for patient
care statistics.
The things that made it, I think, the most critical to me,
as an individual who works with the hospitals on a daily basis,
being in the Health Department, is that the data provided by
the NHSN is timely, it is immediately available not only to the
hospital, but to the CDC and to the State health department the
minute it is entered, and it is useful and actionable data for
the hospital themselves. The minute they enter the data, they
can compare themselves with national rates; it can be
generating reports for specific hospital units to report back
the outcome indicators related to their quality improvement
efforts; and I also knew that if we developed our own system in
New York, it would be to give us the data, but not necessarily
to make it meaningful and useful to the hospitals themselves.
The other thing that went into that was it became really
clear to me, when I was asked by the Presbyterian Network to
come and speak to them about what we were planning to do, and
in that case, just to give you a little background, the
Presbyterian Network has 23 hospitals in four States and two
countries: New Jersey, New York, Connecticut, Texas, and in
Europe. So we sat there and said, boy, if we have legislation
in New York and we develop our own reporting system and our own
definitions, then the hospitals in our neighboring States and
in Texas, in the same network, would not be able to
communicate. They may have different definitions, they may have
different methods of surveillance. Everything would be
different and they could not even compare themselves for
quality improvement purposes.
So that, to me, was an aha moment to say, really, we have
to use a standardized system; we need that foundation to come
from a national level so that every State is not creating their
own silo and they cannot communicate with one another.
And a little bit of icing on the cake was indeed that we
did not have to pay for the cost of developing the system nor
maintaining it, and that the hospitals themselves could use the
system not just for the indicators that we mandated, but for a
full array of infection indicators. They did not even have to
share that data, necessarily, with us, but they could use it
given their local infection control risks and problems that
they identify within their own hospital, which I think is a key
issue as well.
This is not just one kind of infection, and all of our
infections are not easy to measure, and do not come away from
here thinking this is nothing, this has no impact on the
hospitals. Everything they are doing takes major resources to
monitor and monitor the infections well.
Again, we were able to measure and to ensure that our
hospitals were indeed finding the infections as well, because
our legislation provided for an audit and validation process.
So we have gone into every hospital at least once, we have been
in 90 percent of our hospitals twice in the last two years. We
have audited them to find out, one, how they are using the
definitions. We have looked at cases that were reported to make
sure that they were reporting accurately; and also individual
records of patients who did not have infections. We were
looking at those to say should they have been reported, were
there infections that were not reported.
But also we are looking at those records to say why are
some patients getting infections and others not. We use this as
an opportunity to look at prevention strategies that the
hospitals are using, to look at risk factors in the patients,
and to turn that information into usable information, provide
feedback to the hospitals, and also to better enhance the
National Healthcare Safety Network.
Beyond the reporting, we have had a definite commitment to
not just importing data, collecting data, and reporting it out,
but to prevention projects in New York; and we were given, from
the State funds, we were given dollars to provide for
collaboratives in the State. Since 2007, we have initiated nine
healthcare-associated infection prevention projects.
Yes, we have looked at central line infections, but we have
also looked at them in other than ICU settings, where, quite
frankly, now there are just as many central lines being used on
the overall floors and not just in ICUs.
We have looked at our regional perinatal centers, which
take care of our highest, highest risk infants, the newborns
who are born premature, and they are looking at infection
reduction strategies in those units. We are looking at a full
array of multi-drug resistant organisms in our public
hospitals, not just MRSA, not just VRE, but these totally
resistant strains of acinetobacter and Klebsiella that are
killing our patients; and in some of our hospitals they have
had to cut off all antibiotic use in some ICUs in order to get
the organisms back to being resistant to some of our
antibiotics. They have had to say forget it, no antibiotic use
now, because we have made all of our antibiotics obsolete.
We have looked at ventilator-associated pneumonias. We have
a major prevention project looking at Clostridium difficile
infections. We had over 42 hospitals participate. It has now
been expanded to nursing homes in the State. Do not think that
everything is in hospitals as well. We are also looking at
other measures in addition.
So we have demonstrated remarkable reductions in an array
of healthcare-associated infections; not just one bug, not just
one type of infection, but it has come from the local community
to say this is our pressing infection control issue, these are
the major risks we are seeing in this region, please help
support us with that particular type of infection.
We think that flexibility is very important in order to
involve people and to get the involvement not just from the top
down, which is also critical for every one of these efforts,
but from, I would say, the bottom, from the people who are
actually delivering the care, to say this is what we need in
our hospital, this is what we should target, and to make sure
you involve and motivate all those individuals.
I think it is critically important that there is national
leadership on this effort, not to just direct exactly what you
are going to look at, but more to give us that foundation; to
give us the foundation of the NHSN to truly support it to be
able to utilize that system better and more quickly. It does
need enhancements in order to make it more flexible and in
order to meet new and emerging infection threats that we have
not projected right now.
We, as States, I think, need to be involved in the
decisions as to what is a major problem for our hospitals, and
that foresight has to come from the local and State level, and
not just a national imposition of this as being the priority
for every hospital in the Country.
Given that more than 70 percent of the infections are now
occurring outside the hospital environment, many of you may be
aware of the numerous hepatitis outbreaks that have been
reported recently. They are not just occurring in hospitals or
ambulatory surgery centers, they are occurring in basic
doctors' offices, where invasive procedures are now being
performed; and there is absolutely no oversight in those
facilities. There are no regulations of those facilities. We
are now mandating accreditation in New York State, but we still
do not regulate those settings.
We receive over 1,000 outbreak reports a year in New York
State in our healthcare facilities. It is not just hospitals,
it is our long-term care facilities and these other sites.
We need to be able to monitor things not just with the
NHSN, but there are other electronic solutions that can be
there, that are available in a few States. New York happens to
have an extensive electronic laboratory reporting system, but
this needs to be across the Country and not just in New York
State. Even our public health labs do not have electronic
reporting; less than half of them do.
Our IT systems need to work together. You have already
heard from others on that. We have mandatory infection control
education in New York. I will tell you, every four years, every
provider has to go through this. I cannot tell you that they
all listen, that they all hear and they all implement
everything that they do. I think so much of their training has
already been ingrained.
And if you think there is a major component in the medical
school and nursing school curriculum on infection prevention
and control, you are mistaken. That has gone on the wayside.
Why? Because we have more technology to teach, we have more
this, more that. Infection control is not a priority and
absolutely needs to be.
When manufacturers are making these new stellar devices
that can go to all parts of the body through a small hole, that
is great. But they are not putting infection prevention and
control in the design of that piece of equipment. Infection
prevention and control has to be a priority in medical device
design, in the way we manufacture medications, the way we
dispense medications. To me, it is despicable that we have
individuals using multi-dose vials on multiple patients, and
the inadvertent reuse of a single needle or syringe can lead to
infection in 50, 100 or more patients just by one error. We
have to build these errors out of the system. We have to
engineer them away.
Anyway, we have only had a short time. I hope I have given
you some idea of what a State can and should be doing. But
there are not the resources to do this. We really hope that we
can work together to achieve success in this area.
Mr. Obey. Thank you.
[The information follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Dr. Hyzy's Opening Statement
Mr. Obey. Dr. Hyzy.
Dr. Hyzy. Good morning, Mr. Chairman. I am Dr. Bob Hyzy. I
am a pulmonologist and critical care medicine doctor at the
University of Michigan Health System in Ann Arbor. I also chair
the steering committee of the Michigan Health and Hospital
Association Keystone IC project. And along with the work of
dozens of people, I implement a Keystone at my office and work
with the State association to provide local expertise in
conjunction with national leaders, such as Peter Pronovost, who
I am proud to share the table with.
You have already heard today a little about Keystone ICU.
It was a multi-faceted project. The landmark accomplishment, of
course, being the reduction in catheter-associated bloodstream
infections. The specialized catheter we use in intensive care
because the patients are too sick and cannot tolerate the
Perfil catheters.
You have heard how our median catheter rate has gone down
to zero and you have heard about the notion of saving 1500
lives and almost $200,000,000.
At my own hospital, we have dropped our rate 74 percent. We
are doing a lot more at my hospital. Sanjay Saint, a national
leader, is working with ureter catheter infection reduction
through State. We heard a little bit about medical schools. I
am working with some of our people with regard to our third
year medical student curriculum with respect to patient safety
education program.
But I want to speak a little bit about Keystone and maybe
kick the tires a little bit to make some suggestions with
regard to what works and why. There are a number of facets to
Keystone. I think first and foremost is leadership at the local
level, at the hospital. The hospital administration had to get
involved, they had to be supportive of what transpired in the
critical care unit. The quest remains, certainly, some data
collection elements required some money for full-time
equivalents for collection. So their support was critical.
I think most importantly--and I am sort of a bottom-up guy
working in the field--you had to engage everyone with the
experience. I think quality is everyone's business; you cannot
just rely on some external agency. Our infection control
committee is going to assess us and tell us what to do. You
have to own it. And I think that is the key piece here. You
have to have data; you have to have good data. You have to
measure; you manage what you measure. You have to have reliable
information that you can share and compare and benchmark.
The MHA, I think, was also instrumental in this. One of
Peter's key insights for this program was to choose the State
as a logical entity for a collaborative, and you might be a
little bit surprised. We compete with one another for business.
We have got our billboards on the freeway, but, yet, at the
State level, this program worked. Competitors came together to
try to improve quality, created a bandwagon effect, in essence,
where no one wanted to be left behind and not participate.
So MHA was very instrumental in supporting us with
leadership, clinical expertise, information about how to change
culture. Our meetings that we have every year, 300 to 400
people in the room, critical opportunity to interact with one
another; the conference calls that we have with 100 or more
people on the phone throughout the State with Peter or our
local leaders to help move care forward are all key elements.
I also wanted to point out that the original AHRQ grant
ended in 2005, four years ago, and I guess it is additional
testimony to Dr. Pronovost that we are still doing it, we are
still going on. And the key word there is culture. I think what
the original Keystone ICU project did have happen is a
permanent change in culture, at least in our critical care
units, and this is what we have been able to keep going now
four years later. So when we talk about the lives saved and the
cost-avoidance, we are still doing it. The levels are still low
and, like I say, the AHRQ grant ended four years ago. So it is
a change in culture I think that is so critical to work from
the bottom up.
And it is true the hospitals across the Country are very
interested in this program and want to participate. With AHA's
Health and Research and Education Trust and the money from
AHRQ, Peter has now embarked on a 10-State rollout being called
On the CUSP: Stop BSI.
So the idea here, and I think it is a great one, is to take
that nidus, that beachhead, that Keystone ICU has created to
try to roll that out, to get that same cultural change. Yes, it
is a checklist. Yes, you have to do the right things. But
without the bottom-up approach to culture, I do not think you
can be successful over the long haul. If you teach the test, if
you just accomplish a task, if you just have reporting, I do
not think you impact medical culture on a permanent basis.
And I know from my experience, meeting people across the
Country, they come up to me and ask if they can be one of the
States. I say, I am sorry, you have to talk to this guy; that
is not up to me.
So I think the idea, then, would be to take this beachhead,
roll it out first with BSI, as we intend to do. And I think
there is an opportunity across the board for other kinds of
infections: surgical infections you have heard about, urinary
catheter infections, and then maybe also beyond the infection
HAI sphere.
So what can Congress do to help? Well, one thing they can
not do is impose additional reporting burdens on top of what we
already have. You know, the AHA has got the hospital quality
lines. There are 4,900, I guess, of 5,000 hospitals already
volunteer reporting. I think reporting is important, but I
think not only outcomes, but process reporting. It is not just
a question of what your infection rate is, it is also a
question of are you doing the right thing.
I work in a tertiary care hospital, solid organ
transplants, bone marrow transplants, a lot of immuno-
suppressed patients. My hospital is not necessarily the same at
all as a community hospital 20 miles down the road, which has a
six-bed ICU. We have over 100 ICU beds. So the process measures
are equally important, to know that you are doing the right
thing.
So I see this as an opportunity, then, to not overburden
with additional reporting, but to create an organic system that
spreads throughout the land, and I think it is a huge
opportunity. So what can Congress do? Well, we have already
heard mention, I guess with the support with the Recovery
Reinvestment Act, the money that is going forward to help this
next step that Peter has in mind.
I mean, obviously, I am a little bit biased. I was involved
with this project. I am involved with trying to continue its
success. He has asked me to help out to whatever extent I can
with this rollout and, quite honestly, it is a pleasure. This
is what he does; I do lots of things. This is more of a labor
of love.
This is not the main focus of my academic ivory tower
career; this is an important thing. I am the medical director
of an ICU. When Peter and Chris Goshel decided on this project
five years ago, the second I heard about it I said we are in,
count us in, this is important, we need to be part of this.
And just to give you an example of the cultural change, my
ICU nurses are getting a little tired of me trying to impact
care and change everything. They first sort of rolled their
eyes at me and said now what does he want me to do. I said, no,
no, you have got to stay with me on this one, I think this is
really good and going to be really important. And I think that
certainly the facts have borne out the case.
So I appreciate the efforts being made by Congress's
support of research and quality and rolling things out. I think
that is the way forward. Again, I am biased. I think Keystone
worked; I think it continues to work. I think there is a core
element of truth there, the operative word being culture.
Checklists are important; documenting that you do the right
thing, process measures are important; but without the change
in culture that is organic and bottom-up, I think ultimately
you do not accomplish anything over the long haul.
So I thank you for the opportunity to speak with you today.
I would be happy to answer any questions and would like my
written document entered in the record. Thank you.
[The information follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Obey. Mr. Tiahrt.
Mr. Tiahrt. Thank you, Mr. Chairman.
INFECTION DATA REPORTING TRANSPARENCY
Dr. Hyzy, in your written testimony there seems to be a
difference of opinion as to what systems hospitals should use
in reporting infection data, whether the reporting should be
mandatory or voluntary. You, I think, favor the voluntary.
Am I correct? And if so, could you elaborate why you think
there is a difference in this conflict and why voluntary is
more important?
Dr. Hyzy. Well, again, I think, personally, the
transparency is important, and I think that hospitals who
legitimately take quality to heart would be the first ones to
want to step forward and report how they are doing. So I see
that as an opportunity. I see that as something that hospitals
are increasingly embracing.
Arguably, the quality movement, if you date it back to the
IOM report in the end of the 1990s, the emphasis in the
hospital culture has not been in this direction for all that
much time historically, 10 years or so. So I think hospitals
are increasingly coming to recognize that stepping forward and
being voluntary with these activities is required. It is maybe
a bandwagon effect. I do not think they need to be dragged
kicking and screaming to the alter of culture of quality any
more; I think that they want to do this and they want to
demonstrate the quality.
So that is why I think voluntary reporting is key. I think
standardizing it--at this point, hospitals get it from lots of
angles, as I understand; everyone is making a demand for this
or that, and I think there needs to be some standardized
approach that everyone can agree on is a recognized mechanism.
This particular issue is not my forte. There are a lot of
agencies out there competing for the attention of the hospitals
and reporting, and I think ultimately, though, it needs to be
decided. I think voluntary is the way to go, but I think some
kind of agreeable approach between these hospitals ultimately
has to be decided upon.
Mr. Tiahrt. Do you think the American Hospital Association,
would all its members be willing to participate in a voluntary
system?
Dr. Hyzy. Well, I believe at this point they say 4,900 are.
So, again, I certainly am here representing MHA and AHA. I can
give you my opinion. I am not of the AHA so much, but at least
as I understand it that is coming to fruition, where these
hospitals are stepping forward on a voluntary basis.
HEALTHCARE PROVIDER LIABILITY
Mr. Tiahrt. We heard earlier that several members of this
Committee think that when an infection occurs or HAI, that a
lawsuit should result. Have you assessed the risk in reporting
these types of infections?
Dr. Hyzy. Congressman, I can speak to that on two levels.
One is my own experience, which is to say in the real world,
physicians are human. We are doing the best we can, and when
you do make a mistake, my own personal bias, and what I tear my
house staff is to come forward and be transparent; say this is
what we were doing, this is why, and this is what we attempted
and this is what happened, and we are sorry, etcetera. So on
that one level I think that transparency is important.
On the other level, you know, the question ultimately
becomes, with regard to what they are calling hacks, is any
event of this nature always constitutes a deviation from the
standard of care, which is what malpractice is. That is why I
think process measures are very important, to be sure that you
are demonstrating that you are doing the right thing.
Again, I am not trying to take a copout. Everyone always
claims their hospital is different. But I can assure you, in a
population of bone marrow transplants, solid organ transplants,
when I say in my document our infection rate is near zero, that
is true. But occasionally our patients will get a vancomycin-
resistant enterococcus in their bloodstream because they are on
five immunosuppressant drugs and that counts as a CABSI,
because we have no other reason for it and there is a line.
Yet, that may not be the source; it may be the immuno-
suppression.
So it is important that you do the right thing, but on
occasion things still go wrong. But a bona fide mistake, I
believe in the hack notion. I mean, if you operate on the wrong
side of the body, that is inexcusable. Are we here to now say
that a bloodstream infection from a catheter will never, ever,
ever happen again, and if it does it is malpractice? I think
that is wrong. What you can do is do the right thing by the
patient and play it smart and demonstrate that you are doing
the right thing, and that, at the end of the day, is all you
can hope for in medicine with regard to infections or any
aspect of medicine.
Mr. Tiahrt. Ms. Stricof, in New York, is there any waiver
of liability through the reporting process, or is it just at-
risk when you do report these things?
Ms. Stricof. Well, there are confidentiality provisions
and----
Mr. Tiahrt. It is nonspecific in reporting? The data are
aggregate enough that it is nonspecific?
Ms. Stricof. The way we report it out is such that no
individual can be identified. Our data also are protected under
the highest level of protection in New York State law, Public
Health Law 206(1)(j). You do not need to know that, but what it
says is that we cannot release this data on any individual; we
can only put out aggregate data. So no one can even subpoena
from the State Health Department with regard to an individual.
That does not mean that aggregate data are not available,
and it also does not mean that a patient, if a lawsuit is to
ensue, cannot go to the hospital and get the information that
they report. But we as a State health department are protected
from providing that information; and that is another feature of
our law that I think is very important.
Mr. Tiahrt. I think that is good information. I think we
ought to pursue it. I sure would like to know before I go to a
hospital.
Ms. Stricof. No, we give the infection rate data. We do not
say whether patient X developed an infection, because that
would be a breach of confidentiality for that individual.
Mr. Tiahrt. I think there has to be some level of security
at these institutions so that they are free to give us this
information so that it is provided accurately and fairly.
Dr. Pronovost. It would be wrong to assume that lawsuits
are not occurring now. There is a class action suit in New
Jersey for people who have been infected. They happen all the
time. The consumer movement and the legal movement is
responding to that. I would be cautious, though, of thinking
that that is going to be an exceedingly effective lever to
improve quality of care in this Country, because its main goal
is to either justly compensate people who have been wronged,
and they ought to be, and, as an incentive, to improve safety,
and it does both of those exceedingly poorly; people are not
compensated very well and there is very little feedback.
As Rachel said, at the aggregate level, it is not patient
identified, it is a rate. I think the far greater risk is
misinformation or partial truth that the data are not accurate;
they are using administrative data or billing data that is more
likely to mislead than really inform the public.
Mr. Tiahrt. I just think with 1.7 million occurrences, that
1.7 million lawsuits would not be helpful.
Thank you, Mr. Chairman.
Mr. Obey. I am trying to remember the words to the old Tom
Paxton song about 1 million lawyers, but I will not recite it
here.
Mr. Ryan.
NURSE AND HEALTHCARE WORKER SHORTAGES AND OPERATING COSTS
Mr. Ryan. Thank you, Mr. Chairman.
I just have one question. A lot of the previous panel and
now the second panel have talked a lot about kind of
standardized procedures and kind of the technical engineering
the problems away, and I just have one question, if you all
could just kind of give your opinion on it.
What effect does the shortage with nurses and healthcare
workers have on this? And if there is any way to quantify what
percentage of these situations are a result of the shortage and
the nurses that are overworked and the overall shortage in
healthcare, because it is not just in hospitals that this
happening.
Dr. Pronovost. I will begin with that. Congressman Ryan, I
think that is a substantial issue, and let me give you a
concrete example. In our program, we require a hospital to say
nurses will assist the physicians putting in these catheters
and ensure that they check it off. So the nurse is essentially
the police person or the auditor to say, yes, you are doing it
correctly.
And we get, including at my own hospital, a well-resourced
Johns Hopkins substantial push-back to say there is no way I
could afford a nurse to do that, and they are absolutely right.
We are making tradeoffs about allocating our resources all the
time, and it plays out, with nursing shortages, that you now
have agency nurses or temporary nurses who may not know the
protocols being the ones caring for your patients who do not
have that culture of teamwork to question me when I will
inevitably forget something. They do not know the protocols and
they are stretched doing a million other things.
So I think it is a factor. And you heard many of us say
about the cost savings, and there is no doubt there are cost
savings for quality of care. But what is often neglected is
there first needs to be an investment in resources to collect
data, and that is an expense that has to be incurred. And the
savings are down-streamed. Quite frankly, most of them get
passed on to the insurer, they do not stay with the hospital,
which is why many of us believe they ought to be the ones
funding a lot of this work because they are the ones who
ultimately save the most financially.
But without some investment in hospital resources, I think
it is a significant barrier to doing this work.
Dr. Hyzy. I would only echo what Peter said. At the ground
level, what it is, when you are short, you hire an agency, and
the agency people are not involved with your program; they
parachute in for a shift and you have to pay them more, so it
increases your costs. But that is where the problem is. If you
want a culture and you want to sustain it, you have to have
people who are more invested than just come in for one shift.
Ms. Stricof. I would agree, and it is not just--I think the
way you phrased it was a shortage of nurses, and even if we
were to overcome the nursing shortages, which I think we are
almost on our way to doing, it really is what are the staffing
resources and what are we willing to pay for healthcare
delivery.
I think one of the factors, I believe it was Ms. Lee; I may
be mistaken--who said I had to be there 24 hours when my family
member was in the hospital. What is the education and
background of the individuals that are now providing care, and
how extensive is that care? How much time are people able to
spend? And, quite frankly, part of this is no one would go into
an OR and not scrub and not gown and not do that. When you are
on the floor and you are covering 15 or 30 patients on a night
shift, and somebody calls for you, it is really hard to go from
patient 1 to patient 2 and ideally put on a new gown and gloves
and perform hand hygiene.
If it were simple, if it were leisurely, if it was
available, we do not go into healthcare and try and harm our
patients. It becomes a matter of the system and the
infrastructure that is there to support doing the right thing
and knowledge.
Mr. Ryan. Do you have like a percentage that you--I know
part of this is for us to figure out exactly how this is all
happening. Do you have any ideas, 1 in 10, 2 in 10 is affected
by the nurses parachuting in and out? I will let you just
answer those questions. I think this speaks to the point that
this is not a single shot where this is the only issue. This is
about nursing education; this is about community colleges; this
is about Pell grants; this is about student loans. This is
about all of those things and addressing this in a
comprehensive way, not just--although what you are talking
about is extremely important and vital to solving the problem,
this is, I think, about all of us figuring out how we address
this from all sides.
So if you could just give me your opinion, even if you are
lying to me, just give me----
Ms. Stricof. I will honestly tell you that I do not know.
And I do not think you can make that up because part of the
problem with any pre-established number is it assumes that
everything is stable and the same, that all the patients on the
unit require the same level and intensity of care. It also
means that every individual, just because they are an RN or
even an LPN or even a patient care tech, has that same level of
education, training, and capability and that they know their
hospital system, that they are already ingrained so the
educational level, their familiarity with where they are, and a
lot of places do things very differently.
I wish I could give you that, but I was actually thrown out
of a lot of conversations at the State Health Department level
because I wanted to seek adequate staffing levels and we could
not come up with them.
Dr. Pronovost. I would be guessing, but I would say it is a
substantial portion. I would say it is certainly more than 10
percent. It happens all the time at my own place, where someone
gets pulled away so there is no one there to audit the
checklist. And what I applaud you for is to recognize that this
has to be a comprehensive approach that includes education,
that includes payment reform, that includes measurement; and I
think the plans outlined by Dr. Wright under the Secretary's
plan for infections are in that correct direction.
Right now, I have a medical student with me from Johns
Hopkins who is doing work with us. We are one of three medical
schools that requires a safety course in this Country right
now. It is appalling, and yet we are getting graduate medical
education dollars from CMS and we are putting out people who
can look at pathology slides, but not necessarily know how to
standardize and deliver safe care or work as part of a team,
and I think that needs to change.
HEALTHCARE INVESTMENTS
Mr. Obey. Let me ask just a couple questions before we wind
this up.
Dr. Pronovost, you, a number of times, have said that we
needed to invest in science of health delivery. When you are
talking about investing, what is it that you mean? I mean, what
is it that we should be doing in the Congress in this regard?
Dr. Pronovost. When I say that term, I look at the
shortcomings in quality and safety, and they have been the
subject of many of these hearings, and the approach is often I
get angry and I tell people to try harder. It is better
management. And our CEO has really called to task department
chairs for not getting their infection rates down, and they
come to me and say, Peter, I wish I knew how to do that; I do
not have a clue. What is the science to guide me? And I think
the mistake that we have made is thinking the delivery of
healthcare is just trying harder, it is pure management.
There is no doubt there is a management component, but
there is a science of how do you do behavior change. What is
the impact of payment policy? How do you measure these things
accurately? And we spend a penny on the science of healthcare
delivery that we do finding new genes and new drugs.
So specific things I would say build capacity. I, at a
place as well endowed as Johns Hopkins, am one of one or two
people who could actually teach this stuff. We have probably
200 people who can teach genetics, because there has not been
funding programs to train people in the science of healthcare
delivery.
When you look to get funding to say, okay, let us develop a
new Michigan program for urinary tract infections or blood
clots, there are, frankly, little places you can go to get
funding, compared to if I wanted to study a new gene, I can go
to the NIH and there are enormous resources. And I am not
saying we do not need those resources, we do, because I think
we want to keep being the world's leader in science. But we
have to shore up the other ones because there is just not a
pipeline for doing these things.
And then I think for when we do find good programs and the
science that works, like we have in Michigan, what is the
investment to spread them? Because, again, there is some
management component and making these measures public is going
to be a part, but States are struggling, and I think payment
reform alone is likely going to be pretty anemic. At least the
evidence to date shows us that it has some role, but it is not
going to be a blockbuster. We need to also do wise investments
to not just put these programs in, but what lenses are we
taking to learn, so that there is some study of what we are
doing with this now 10 or hopefully greater State project, so
at the end of it we can sit at the table with HHS, CDC, AHRQ,
the States, researchers and say, okay, what did we learn that
is going to allow us to do the next program more efficiently
and effectively?
Right now, what we have is hospitals doing their own thing;
they are all summarizing their evidence, they are all trying to
develop their own measures, they are developing their own
curriculum and it is, frankly, a waste of resources.
I will give you a concrete example that we did. In this
Country, in every hospital each year some patient gets an
epidural catheter that is often used when women are having
babies or for pain--you may have had one after your knee
surgery--connected to their IV catheter, and that epidural
medicine is potentially lethal, could kill you. And the
solution is to tell nurses to be more careful or doctors to be
more careful, to re-educate them. And we modeled it out. Given
that--AHA experts, correct me--there are somewhere around 1.9
million nurses work at the hospital, and say that that
education takes an hour and it is $50 for an hour of a nurse's
time. That is about $75,000,000 a year spent on doing something
that has a zero probability of working. That is insane, and we
do it all the time.
What makes much more sense is to say, well, why do we not
design that catheter so it cannot fit together? Yes, there are
going to be some up-front costs, but we would lick the problem.
Just like you cannot stick a diesel gas pump into your
gasoline-powered car. But we have not invested in the science
of how to do that, so we keep plodding away, every hospital
inefficiently doing their own way.
And I am not for taking away that innovation, but I think,
just like with financial reform or education reform, it is not
a choice of whether you take a regulatory or a market approach.
What we ought to say is what makes wise, what is more efficient
to standardize and centralize? And I think standardizing the
science and the measurement, and then letting hospitals work on
what are their main problems and innovate, and being held
accountable for doing it. But we need that balance and we do
not have it right now, I think because we do not even know what
to measure. There just has not been an investment like we have
in other areas of science.
Mr. Obey. The two of you represent approaches that have
been very different. If you take a look at New York and
Michigan, you have, in New York, reporting on a mandatory
basis, and you do not. Give me the pluses and minuses, the ups
and downs of both of those approaches.
Ms. Stricof. I do not think they have to be exclusive of
one another. Maybe you see them as very different, but I think
we have taken different approaches but integrated some of the
same thing. We mandate the reporting of data. What I--and I do
not want to speak for this, but by not auditing the data that
has been reported by the Michigan hospitals, I do not really
know that all the hospitals are measuring things in the same
way. I do not know that the patients--all the facilities who
say they have had zero ventilator-associated pneumonias--and I
am picking that because I think there is nobody who can
systematically diagnose that properly. So I am going to tell
you that I do not know the impact of that because I do not even
think every hospital is doing it the same way.
So I think a combination of efforts can be very important
and achieve the same thing. I think to put a lot of meaning
into a sign on the door that says my hospital rate is such-and-
such, when the hospital is in total control of defining what
that infection is and how to count it, then I say that is
meaningless, because I will tell you, when I talk to the
cardiac surgeons, none of their infections are infections, and
when I talk to the colorectal surgeons, theirs are not
infections; they were all patients who came in infected, that
was there to begin with. You are not going to count that
against me; we need an objective view.
If I am going to give the public the data, I want to know.
If that is what is mandated from me, then I am going to make
sure that that report is as accurate and meaningful as
possible. And while trying to do that I want it to be useful to
the hospital as well.
So I think what he has done has done miraculous work, and
we have tried to copy and emulate what he has done. I am just
saying that maybe I do not trust the data as much, but I think
they have made a remarkable impact. So if it is not by this
percent, it is by this percent. That does not matter as much to
me.
Dr. Hyzy. I think that ultimately a volunteer participation
and culture is the better way to get accurate information. You
know, I think it is actually wrong to state that we are not
attempting to standardize our approach and what definitions of
infection is, either it is a vap or a cath-associated, that is
exactly not true. We actually do standardize our approaches
and, in fact, rigorous data collection is one of the greatest
strengths of what we have and it is not just every sort of
hospital for itself to decide what is and is not an infection.
I think by creating a culture and getting voluntary
participation reporting, you are far more likely to get
transparency and accuracy than when you engage in sort of,
again, the top-down punitive manner. So it is actually the
active engagement of our institutions that has given this legs,
has made this sustainable, because people take it to heart.
But do not think for a second, Mr. Chairman, that we do not
have a fairly rigorous approach to data definitions and data
collection, because without that we know we are nothing; and we
have that. And that was actually one of the great successes
that we have had is data. Without the data, we are nothing. And
data definition. So that is I think what gives us credibility,
is that we do have data and it is meaningful.
Mr. Obey. Last question. What is the biggest single barrier
at the hospital level to seeing this job done the way it ought
to be done?
Dr. Hyzy. I think it is often money in a certain way,
because I sit in the ACCP, American College of Chest
Physicians, a quality improvement committee, and we have looked
at an array of performance measures that the National Quality
Forum has advocated for, and they have got criteria about
feasibility. Feasibility. Well, if you look at these
performance measures, you are having an unfunded mandate on the
hospital to collect data. Who is going to collect that data?
Collecting data at this point requires people.
Now, until we all have electronic medical records where you
can create a little computer program and all this data is
getting entered and you just push a button and spit out a
performance measure, until that point, it is people, and people
are salaries and benefits, and that is extremely expensive.
That is why one of the key components with regard to
Keystone success was support by the hospital administration
leadership. And our nurses would say, when we go to our
meetings, they will say because of Keystone's reputation, the
ICU head nurse would say I need this or that because Keystone
wants it. With the support of the administration, then they are
willing to make a little extra effort to spend that money that
is required. But it is a money issue. You cannot have data at
this point. I wish we were at a point where we could just push
a button, but we are not. It is people going bedside to bedside
collecting data, and that is not cheap.
Ms. Stricof. I just think with each--they have made a
commitment to select infections, which I think is absolutely
critical. They found ways to work and to try and reduce those
selected infections. The question is what do we as a society or
the public want to know about. I would say how many--you know,
is it this infection or that infection or you know, everything
is a matter of resources. It is where do I dedicate resources.
Ideally, quite frankly, I was not 100 percent a proponent
for mandatory healthcare-associated infection reporting. The
fact was we passed legislation. I think we have also seen the
effect of mandating these select indicators, because for our
select indicators collaboratives evolve. The minute they knew
and they put on there that we were going to monitor central
line-associated bloodstream infections in ICUs, we had every
hospital--well, not everyone in Greater New York got to sign on
of 37, then added another 19 hospitals among their 90-some odd
members who volunteered to participate because they knew that
that particular infection indicator was going to be monitored
by the State and was going to be made available to the public.
I think that both can work hand in hand. I am not such a
separatist. And I am not saying that--I am just not sure that
there is one answer to everything.
Dr. Pronovost. I think there are resources, but that it is
solvable; that the hospitals should be provided methods to
accurately monitor data. It is crazy that every hospital
develops their database. I think things like NHSN are a model
for how to do that. They ought to be provided what the evidence
is in a digestible format.
I completely agree that the public ought to be ensured that
data is accurate. There ought to be auditing. I wish I had
authority to audit data in Michigan. It was a voluntary thing,
but the reality is reporting of healthcare quality in most
hospitals is like Enron. That is the normal reporting rather
than the exception in the world, and the public deserves
better.
I do believe there are resources because we have cut
margins so much in healthcare that staff have time to do the
work barely. But managing the work takes effort. So someone has
to collect data; someone has got to train people and educate
them. And we have ratcheted down the reimbursement so much that
at my hospital we have cut all those positions, so the nurse is
at the bedside, but there is no time for you to work on these
projects. And it is kicking out resources, as I said, but it is
staying in, likely, the insurer's pocket; and I think we have
to think about reinvesting those so that hospitals do have the
resources to collect data to participate in these programs and
the society will see the cost savings that we all hope for.
The investment in health IT is an enormous opportunity, but
I hope it is linked to measuring quality and reducing costs. If
it is divorced from that, I doubt you are going to get the
returns that are anticipated in the budgets. You will have a
very expensive medical record, but not improvements of quality
if we do not build standards for these measures and cost
reductions into it.
Mr. Obey. I just wish this were as simple as guaranteeing
that my Uncle Dan's patients, when he was a dentist, would have
received quality treatment. The best way to guarantee that was
to see to it that they saw him before 2:00 in the afternoon,
before the Jack Daniel's got to him. [Laughter.]
Mr. Tiahrt.
Mr. Tiahrt. Thank you, Mr. Chairman.
Dr. Pronovost mentioned that one of the reasons we have not
had more progress on this is these 100,000 deaths a year are
invisible, and I think the record should show that the
visibility that you are giving this issue actually started
behind closed doors in conference committee last year, and I
want to thank you for your leadership, because it is an
injustice that we want to correct. And I think making it
visible is going to get it a long way down that road to
stopping 1.7 million HAIs. So thank you for bringing this
hearing together and thank you for your leadership on this
issue.
Mr. Obey. Thank you.
And let me thank you all for coming. I appreciate it. Keep
doing what you are doing.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Tuesday, May 12, 2009.
U.S. DEPARTMENT OF LABOR
WITNESS
HON. HILDA SOLIS, SECRETARY, U.S. DEPARTMENT OF LABOR
Chairman's Opening Remarks
Mr. Obey. Well, good morning, everyone.
Mr. Lewis. Good morning.
Mr. Obey. Good morning. I am pleased to welcome our former
colleague and new Secretary of Labor to her first appearance
before this subcommittee. Madam Secretary, you face some pretty
daunting challenges. The country is experiencing the longest
and the deepest economic downturn since the Great Depression.
More than 5.7 million jobs have been lost during the recession.
And that understates the true gap between how many jobs there
are today and how many are jobs needed simply to keep up with
the growing population.
The economy needs to add about 127 thousand jobs each
month. That means the economy is nearly 8 million jobs below
where it needs to be just to maintain pre-recession levels of
employment for the American workforce. Nearly 14 million
unemployed Americans are actively looking for work, with
3,700,000 people out of work for more than 6 months. That is 27
percent of the unemployed persons in April, the highest
proportion of long-term joblessness on record.
That indeed is something to worry about. And I think the
crisis is magnified for the American workforce because their
problems are not solely the result of the current economic
downturn. The earnings disparity between the working class and
the wealthiest workers has been growing for the past three
decades. Between 1979 and 2000, real after-tax incomes grew by
256 percent for the top 1 percent of households. That compares
with 21 percent growth for households in the middle fifth, and
11 percent growth for households in the bottom fifth of the
income spectrum. One of the primary drivers behind that growing
earnings disparity is the inability of workers to reap the
economic benefits of their increased productivity. And that is
at least, in part, a result of the decline of unionization.
During our post-World War II economic expansion, the so-
called heyday of the American economy, union membership
fluctuated between 30 and 35 percent of the workforce. By 2006,
it had fallen to 12 percent, including only 7.4 percent in the
private sector. And according to the Economic Policy Institute,
the gap between pay and productivity growth is the result of
economic and employment policies that shift bargaining power
away from the vast majority and toward employers and the well
off. I would hope that to confront this rising income
disparity, this administration will refocus on programs and
policies that help our Nation's workers and strengthen the
middle class, the foundation of our Nation's economy.
I am pleased to see a number of items in your request,
including investments in green jobs, YouthBuild, and the Career
Pathways Innovation Fund. I am pleased to see a request for
increased funding for state unemployment insurance operations.
I am also pleased to see the Department renew its focus on
workplace health and safety. In 2007, 5,657 workers died as a
result of job-related injuries, an average of more than 15
deaths a day. And as many as 8 million to 12 million workers
sustain job-related injuries or illnesses each year.
Approximately 50 thousand workers die each year from illnesses
in which workplace exposures were a contributing factor. Let me
put it this way: While I am positively impressed by most of
your budget, I am concerned about a couple of items.
As you know, the Congress included $250 million in the
Recovery Act to train workers for high growth jobs, especially
in the health care sector, which continues to add jobs, one of
the few sectors of the economy that does. The BLS reported last
week that the health care industry added 17 thousand jobs in
April, in line with its average monthly gain since January. In
2008, the average gain was 30 thousand jobs per month. However,
your fiscal 2010 budget does not appear to continue any
targeted investment to address the critical shortage in the
health care workforce, including a long-term need for 2.8
million nurses and nearly 2 million allied health workers.
It seems to me that if we are serious about significant
health care reform that we have to build the capacity of the
system, and we are falling short in this area. I am also,
frankly, disappointed by the administration's proposal to
freeze the number of participants in Title V Community Service
Employment Programs for older Americans. There are a lot of
good reasons why this program ought to be expanded. The most
important reason, in my judgment, is that the unemployment rate
for seniors age 65 and up is at its highest recorded level
since the Federal Government began tracking this figure after
World War II, according to a recent report by the Urban
Institute.
Let me simply conclude by saying that, on balance, I think
you are presenting a strong budget, certainly one that I think
represents a much greater effort to meet the needs of workers
than the budget we received a year ago. But I still think that
there are gaps that the administration needs to be aware of and
consider, and I look forward to working with you as we deal
with these issues in the coming weeks. Mr. Tiahrt.
Ranking Member's Opening Remarks
Mr. Tiahrt. Thank you, Mr. Chairman. I know you have been
quite anxious to get moving forward on the administration's
budget request and begin the committee's work. First, I would
like to welcome our new Labor Secretary, our former colleague,
Hilda Solis. Congratulations. And I hope you enjoy your
experience on the other side of the dais. Today more than ever,
Americans eagerly await the news from the Department of Labor,
hoping for good news about job growth. And our task in Congress
is to ensure that you have the tools necessary to help our
fellow citizens realize their dreams. It is in this vein that I
am sure all my colleagues, as well as myself, examine the
Department's budget request. Last Friday, the Department of
Labor's Bureau of Labor Statistics announced that the Nation
lost 539 thousand jobs in April, and that the unemployment
rates rose to 8.9 percent from 8.5 percent in March. In
addition, the Bureau reported that for the 12-month period
ending April 30th, the Nation lost 5.24 million jobs, a
decrease of 3.8 percent. We can only hope that this news could
be the first indication that the pace of job loss may be
slowing.
Remarkably, in April of last year, the unemployment stood
at only 5 percent. Today, Americans are facing the kind of
economic conditions that would have seemed unfathomable a
couple of years ago. In fact, since the recession started, the
Nation lost 5.7 million jobs, the deficit soared to over $11
trillion, and Congress faces daunting choices. In the last 100-
plus days alone, the deficit has increased with the
administration's spending spree in the stimulus bill, the
omnibus, and the supplemental. We are printing more money than
we can keep up with. And I am concerned about the long-term
effect on our economy, especially jobs.
Let me start by saying I appreciate that on the
discretionary side, you have requested only about a 3 percent
increase over the fiscal year 2009 non-Recovery Act budget
authority. Nevertheless, prior to considering this budget
request, it seems only logical for Congress to ask what has
become of the $4.8 billion in discretionary budget authority
that Congress provided to the Department of Labor in the
Recovery Act. How much of the funding has been expended? What
has been accomplished so far? It has come to my attention that
the Recovery Act reports, while featured prominently in the
Department of Labor's Web site, have since their inception been
decreasing rather than increasing in program level obligation
and expenditure detail. Naturally, I have concerns about this
fact. This seems to be the antithesis of transparency that the
American public was promised.
Furthermore, the Department of Labor seeks appropriations
that will maintain funding for some programs at levels more
similar to the augmented fiscal year 2009 levels. Congress
needs to consider whether program levels can be justified at
this time. One example is the YouthBuild program. The Budget in
Brief states few studies of YouthBuild demonstrate promising
results. And it designates significant increases in budget
authority for both YouthBuild program level and its evaluation.
Saying a few studies detected merit with respect to YouthBuild
raises questions about the studies which have not found merit.
In fact, our own government's evaluations have identified a
number of shortfalls in this program. Seeing as how YouthBuild
just received an infusion of $50 million in Recovery Act and in
light of the Department's tepid, if not cryptic,
acknowledgement of YouthBuild's lack of notable success, I am
curious as to why the Department seems to want to gamble on
YouthBuild's track record with a $45 million increase in
program level funding. That is about a 64 percent increase over
fiscal year 2009. This seems to be counterintuitive.
I would think that there would be more than enough activity
generated by the additional Recovery Act funds to support a
thorough evaluation of this program. And that evaluation would
be more properly conducted prior to the appropriations of
significant increases to the budget. Another concern I have is
the notion of green jobs. The President desires to
simultaneously create new green jobs, stimulate the economy,
and wean America off foreign oil. This is a social experiment
that appeals far more to environmental interests than our own
workforce community.
A study conducted by King Juan Carlos University in Spain
found that based on the European or Spanish model cited by
President Obama as the model for green policies, they are
likely to destroy upwards of nine conventional jobs for every
four green jobs created. I find myself quite reluctant to
support policies underlying the need for green jobs training.
This poor timing of the scheme cannot be overstated, in my
opinion. I am further concerned that these jobs will be just
temporary, and too few in number, and will fail to justify the
level of government intervention being directed at them. The
net reduction in the budget request for the Office of Labor-
Management Standards also concerns me.
The Office of Labor-Management Standards is the lone
Federal agency with the job of protecting workers' interests in
how their unions are managed. I am not pleased that the
Department of Labor has already signaled it will not enforce
compliance with current conflict of interest disclosures in
addition to recommending that we slash funding for this
extremely important division, all the while announcing its
desire to increase worker protection. The fact that from 2001
to 2008, the Labor Department secured more than 1,000 union
fraud-related indictments and 929 convictions proves that the
workers deserve protection from more than just employers in
many cases.
I oppose the reduction in funding for the OLMS, and intend
to watch very, very closely to ensure that the mission of this
important agency is not being diluted. With regard to the
mission area increases, I would like to take note the of the
Department's request for a large increase in the area of worker
protection. The budget request includes 9.9 percent increase in
the area of worker protection. I think we can argue that safe
and fair workplaces should never be a luxury.
Yet I am curious about the evidence on which the Department
of Labor has based its request for such a significant increase,
especially when the Office of Labor-Management Standards has
been reduced. I look forward to hearing the background on this.
Finally, on a personally directed note, I just want to
mention my desire to work with the Department of Labor to
rectify a situation that has impacted some of my constituents
over the last year. In fiscal year 2007, the Department of
Labor awarded by competitive bid a Garden City community
college in Garden City, Kansas, a community-based job training
grant. The grantee had intended to use the grant to train
workers in the construction of two coal-fired power plants.
Unfortunately, last year the governor of my State blocked the
construction of these power plants, and created a delay which
made it impossible for the grantee to comply with the terms of
the grant.
Recently, however, our current Democrat Governor of Kansas
permitted the construction of the plants to move forward. While
I am aware there may be some hurdles to overcome with respect
to the grant at this time, I look forward to working with the
Department to find a way for this important job training
opportunity to get back on track. I want to thank the
Department in advance for its cooperation on this project.
Madam Secretary, at the end of the day, I am sure we all
want the same thing, high quality, high paying jobs for all
Americans. And it is your Department's responsibility to see
that we are prepared to fill those jobs. Let us know how we can
work together towards that common goal. Thank you, Mr.
Chairman.
Mr. Obey. Mr. Lewis.
Mr. Lewis. Mr. Chairman, outside of welcoming the
Secretary, I am anxious to hear her testimony and participate
in the questions. Congratulations, Madam Secretary, and I look
forward to working with you.
Secretary Solis. Thank you.
Mr. Obey. Madam Secretary, why don't you proceed.
Secretary Solis. Thank you. Thank you, Mr. Chairman, and
Ranking Member Tiahrt, and the subcommittee members that are
here this morning. I especially want to say a thank you for
your gracious welcome, Mr. Chairman and the ranking member. It
is good to be able to see friends here in the House. This is
the first time that I am actually testifying before a
committee. So it is with a great deal of privilege and an honor
for me. So with that, I will begin my statement.
And as I would like to suggest, if I would like to provide
a summary of my remarks and ask that my written testimony be
entered in the record.
Mr. Obey. Sure.
Secretary's Opening Statement
Secretary Solis. The total request for the Department of
Labor is $104.5 billion. And $15.9 billion is before the
committee, and $13.3 billion of the request is for
discretionary budget authority. Our budget for DOL requests
funding programs for the Recovery Act. And we all know that
families right now are struggling. We see this economic crisis
every single day. Investing in our Nation's workforce and
creating new jobs is a critical component of President Obama's
effort to jump-start our economy. The Department of Labor is
using its Recovery Act resources to help ease the burden of
unemployment and to put people back to work. And I would like
to highlight some of our recovery activities, which include the
following: Providing new training and employment opportunities
for unemployed adults, youth, and seniors; enhancing and
expanding the Unemployment Compensation and Trade Adjustment
Assistance Act; and also launching a new COBRA premium
assistance outreach program; and fourth, initiating additional
worker protections to ensure that economic activity spurred by
the recovery occurs in workplaces which respect workers'
rights, which provide safe and healthy environments.
And then building on the recovery efforts, the Department's
fiscal year 2010 budget features three overall priorities:
First, worker protection. We are beginning to restore the
capacity of our programs that protect workers' health, safety,
pay, and benefits.
Secondly, a green recovery. We are implementing new and
innovative ways to promote economic recovery by working toward
energy independence and increasing the competitiveness of our
Nation's workforce.
And third, accountability and transparency. We will ensure
that our programs are carried out in a way that is accountable,
transparent to our stakeholders, and to the public. And in all
these efforts, I am committed to fostering diversity and to
ensuring that our programs are accessible to previously
underserved populations, including those in rural America. And
I am particularly proud that fiscal year 2010 begins to restore
programs to protect workers. These programs enforce laws
governing minimum wage, overtime, family, and medical leave.
They also protect workers' pensions and their health benefits,
while ensuring workplaces are safe and healthy. They ensure
equal opportunity in Federal contracting. And in fiscal year
2010, the Department is requesting $1.7 billion for worker
protection programs, an increase of 10 percent above fiscal
year 2009. By adding a total of 878 full-time employees such as
investigators, inspectors, and other program staff, the budget
will return worker protection efforts to a level not seen since
fiscal year 2001.
Increasing our capacity so dramatically in a single year,
as you know, is unprecedented. And it illustrates, again, the
President's commitment to America's workers and the workforce.
And I can assure you that we have developed an aggressive,
comprehensive, hiring plan which will be implemented as soon as
fiscal year 2010 funding is available. The plan prioritizes the
hiring of multilingual inspectors and investigators to enhance
our enforcement outreach. We will provide additional $35
million to add 288 FTE for the Wage and Hour Division, which
protects over 135 million workers in more than 7.3 million
establishments.
These additional resources will allow the Wage and Hour to
improve compliance in low wage industries that employ
vulnerable workers and youth, increases its focus on reducing
repeat violations, and strategically conducts complaint
investigations. The increase for OSHA will allow it to also add
213 new staff such as enforcement personnel, standards writers,
technical support, and bi-lingual staff to address the changing
demographics in our workplace. In recognition of the work of
our State partners, the budget request includes nearly a $14
million increase in State program grants. The number of
enforcement staff in the Employee Benefits Security
Administration will also be increased by 75 FTE, allowing the
agency to conduct an additional 600 investigations.
To help promote equal opportunity in Federal contracting,
we will expand the Office of Federal Contract Compliance
Programs and the number of compliance officers and other field
office staff by 213 personnel. By returning to fiscal year 2001
levels, there will be a reduction in the Office of Labor-
Management and Standards. And I can assure you that the
resources requested will allow the agency to accomplish its
core mission, and that the reduction in FTE will occur through
the transfer of staff to other protection programs which we
have seen a drop in levels of enforcement over the past 8
years.
The increases in our enforcement programs will also require
legal services and support from the Office of the Solicitor. To
help meet these needs, the budget request includes an increase
of $14,800,000 to support additional 82 FTE. And I am hopeful
that this Congress will endorse our worker protection program
request and allow the Department to revive these programs to
meet our responsibility to all American workers. The DOL is
also currently using Recovery Act funds for a range of other
activities, to provide transitional benefits, job training, and
placement assistance to unemployed workers.
And I want to thank the Congress personally for providing
these dollars. The fiscal year 2010 budget request supplements
the Recovery Act funding through targeted investments in
employment and training programs, and I am very pleased and
excited about the use of innovative strategies and programs
that are designed to increase the skills and competitiveness of
all our workforce. Our $71 million increase in the Dislocated
Worker National Reserve Account will help fund national
emergency grants, allowing for targeted response to large scale
worker dislocations. $135 million for a new Career Pathways
Innovation Fund, which will provide fund grants to community
colleges and other educational institutions to help individuals
advance up the career ladders in growth sectors in our economy.
The Career Pathways program involves a clear sequence of
course work and credentials, each leading to a better job in a
particular field, such as in health care, in law enforcement,
and in clean energy. The budget requests an additional $50
million for enhanced apprenticeships and competitive grants for
green jobs. And we are pursuing those strategies to ensure that
all of our training programs are equipped to provide training
for the new green economy. And have included funds from the
Bureau of Labor Statistics to produce valuable information on
defining green jobs. Within our request for pilots and
demonstrations, the budget includes a new investment of $50
million for transitional jobs to help young and noncustodial
parents gain employment experience and sustainable employment.
The budget also includes $114 million to expand the
capacity of the YouthBuild program to train low income and at
risk youth. This is an increase of $44 million over the fiscal
year 2009 level, and will allow us to build on the Recovery Act
funding for the program. In addition, the request is also made
for $255 million for the Veterans Employment and Training
Services program known as VETS, which contains strategic
investments to allow the agency to do the following, to reach
out to homeless women veterans, to make employment workshops
available to families of veterans and transitioning service
members, and to restructure existing training grants to focus
on green jobs.
These innovative strategies supplement our core workforce
security programs that are extremely sensitive to economic
conditions. Thus, in the budget you will also see an increase
of $860 million for the newly expanded Trade Adjustment
Assistance program and $3.2 billion for State grants to fund
the administration of unemployment insurance to support the
increased demand on State systems. In addition to providing
States with the funding they need to cover these increased
workloads, our approach includes an increase of $10 million to
expand reemployment and eligibility assessment to help
claimants return to work as soon as possible. I believe that
spending tax dollars wisely helps the Department achieve our
mission on behalf of American workers and builds trust among
our stakeholders.
A number of other fiscal year 2010 budget proposals support
these goals. For example, the budget request also includes a
$15 million workforce data quality initiative, which will help
us develop data to understand the effect of education and
training on worker advancement. A $5 million increase for job
training program evaluation to help us understand which job
training approaches are more effective, and will help inform
the direction of future programs. And a new $5 million program
evaluation initiative to help the Department of Labor examine
all programs, not just those in employment and training. I
would like to just say a few words about the programs at the
Department. First, the budget does provide $10 million for the
Office of Disability Employment Policy.
The increase will allow us to build on the lessons that we
learned through the Work Incentive Grant demonstration
programs. It will allow us to promote opportunities for
individuals with disabilities, particularly our youth, in
employment, in apprenticeship, pre-apprenticeship programs, and
community service activities. Fiscal year 2010 budget also
includes the program known as Add Us In!, a new grant program
with the Agency's base budget to help minority youth with
disabilities who are interested in entrepreneurship. And
secondly, the budget request provides an increase of $5.3
million, 12 FTE to the Bureau of International Labor Affairs,
known as ILAB. With these funds, ILAB will be able to step up
its monitoring and oversight of labor rights through close
monitoring, reporting on labor conditions worldwide,
particularly with our trading partners. Through these efforts
we can help reduce instances of child labor, forced labor,
human trafficking, and violations of worker rights. Fiscal year
2010 budget will also maintain the child labor and worker
rights technical assistance activities at the same level of
2009.
In conclusion, I am committed to ensuring that these new
efforts, along with all the programs supported by the
Department's fiscal year 2010 budget, will help to demonstrate
that we are working to meet the needs of all American workers
and their families, and I ask for your support and look forward
to answering your questions. And thank you for having me here
this morning. Mr. Chairman.
Mr. Obey. Thank you.
[The information follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Obey. Mr. Tiahrt.
ADVOCATE FOR A SAFE WORK ENVIRONMENT
Mr. Tiahrt. Thank you, Mr. Chairman. There is an overall
philosophical, I think, debate maybe or question that we should
ask with the idea of enforcement. Our current philosophy is one
of adversarial contact. When you think of how the public sector
interacts with the private sector, it seems to be on an
adversarial basis in each case. I had an instance that happened
in Wichita that I think could give us some grounds for a good
debate on how we view the philosophy of our interface between
the public and private sectors. OSHA targeted three counties in
Kansas in the home building industry. This is 3 years ago. They
came into Sedgwick County, where Wichita is located, and
literally shut down the home building business. All the agents
that OSHA had in Kansas came to that area, and they started
writing citations and fines. And I got a call and asked to come
back and meet with the Wichita area builders. I met with them,
and I think it was all summed up by a framing contractor who
said I just recently got a $5,000 citation for having a
Styrofoam cup on the front step of a house that I was framing.
He said my normal profit for a framing job is about $2,500, so
it does not pay for me to go to work while so many of the
agents are in town. He was one of about 6,000 people in the
home building industry that currently were not working.
So I met with the regional, or I called the regional office
of OSHA, and they agreed to meet, which is in Kansas City, they
agreed to meet in Topeka. And together they came up with a plan
that I thought was very interesting. They decided that they
would announce when OSHA would be at a job site. They would
meet with the superintendent or the contractor of that job
site. They walked through the area. They made a list of
violations or potential violations. They agreed to the list,
without any fines and citations. And then OSHA gave them 6
weeks to comply. While OSHA gave them that time, the Wichita
area builders hired an expert out of the insurance industry
that focuses on workplace safety. He came in and conducted
training at each major job site. And they brought people in
from the other sites. When OSHA returned, they went around the
job sites, and they didn't find any violations. And the common
goal was achieved, a safe workplace.
When I talked with the contractors, you know, many of them
hire friends and family, and they do not want anybody to get
hurt on their job. The last thing they want to do is report at
a family reunion why somebody lost a finger or broke a leg,
because quite often it is their own family that is involved. So
I thought this is an interesting philosophy change, where OSHA
actually worked with the private sector to achieve a common
goal of a safe work environment. They were an advocate for a
safe work environment instead of an adversary to the private
sector. And that worked for a couple of years.
And then when the OSHA office here in Washington, D.C.
found out what was going on, they said, no, you've got to go
back to the old method of enforcing regulations, which is this
adversary method. Are you open to discussing how we could
change our philosophy in the regulatory scheme to advocate for
a safe work environment instead of being an adversary to those
people who are keeping and creating jobs here in America?
INCREASE IN FUNDING FOR ENFORCEMENT
Secretary Solis. Thank you, Mr. Tiahrt. I appreciate your
concern and sharing that. That is the first time I have heard
of a citation for a Styrofoam cup. I will certainly take that
information back to my Department. But I do want to say that
one of the reasons that you are seeing an increase in funding
for enforcement is because, quite frankly, over the last eight
years OSHA and Wage and Hour have not received sufficient
funding. In fact, OLMS has received more substantial funding
over the course of the last 5 years. So there was not a
balance. And one of the things I know that the Congress is
particularly concerned about is the fact that there have been
very serious, fatal injuries on the job, whether it is in
construction, the mining industry, or in other service-related
areas. And my concern is not to drive down industry or
business, because what we are talking about here is really
making it more feasible for people to go to work and to be able
to come home.
That is my goal. One of the things that I intend on
providing through our offices in Wage and Hour and in OSHA is
enough technical assistance, not just compliance information,
but to actually provide on-the-job and on-the-site assistance
to those businesses that are open and may not even be aware of
some of the laws and safety concerns and regulations that they
must abide by. I do not expect that we are going to go out of
our way to just create a problem for businesses. Right now we
know that we need to have jobs. And one of the things is, my
highest priority is to make sure that we find people
employment. Secondly, the goal of the DOL, Department of Labor,
is to provide safety and protection for them to be able to come
home. I have traveled to different parts of the country where I
have heard stories where people have lost family members, have
lost their lives because there was perhaps an employer not just
once or twice, but repeatedly did not abide by citations or
particular penalties. That, to me, is egregious and should not
be--that should not be tolerated. I think that we do not have
enough resources in our budget to go after everybody so I have
asked my staff to come up with a plan to work more
strategically. We do not have time to waste taxpayer dollars.
But I will not tolerate when I see someone abusing
periodically, time and time again, their workers in a way that
puts them in harm and then causes----
Mr. Tiahrt. I think we would agree--my time is almost out,
excuse me, Madam Secretary--I think we would agree that when
you have somebody who egregiously violates, they should be
reprimanded at the most severe levels. But I would hope that in
the future we would work with companies that are trying to
comply, educate them in the regulatory scheme.
Secretary Solis. And I would be happy to work with you on
coming up with a program that looks at that.
Mr. Obey. Mr. Jackson.
REDUCING UNEMPLOYMENT DISPARITIES
Mr. Jackson. Thank you, Mr. Chairman. And let me also
congratulate Secretary Solis for an extraordinary job that she
is attempting to do at the Department of Labor under
extraordinary economic circumstances. I have two questions. One
I think is thoughtful because my staff helped prepare it, the
other of which I am trying to formulate. But let me start with
the thoughtful question. Earlier this month, the Bureau of
Labor Statistics reported the national unemployment rate at 8.9
percent. The unemployment rates for white Americans stood at
8.0 percent, 11.3 percent for Hispanics, and a high of 15
percent for African Americans. Currently, African American
workers are experiencing close to double the rate of
unemployment as white Americans in the United States. In my 14
years representing the second district of Illinois, I have
worked to increase access to high quality education, to reduce
health disparities, and increase job opportunities for minority
communities, for which my district is mostly comprised.
What is the Department of Labor and this administration
doing to reduce unemployment disparities? Can you point to
specific programs and job training programs that will work to
reverse these trends given the density of some urban
communities and the nature of unemployment? And then I have a
second question.
Secretary Solis. Thank you, Congressman Jackson. And I
appreciate that question, and, of course, your leadership and
also Congresswoman Barbara Lee's continued leadership on this
effort. I too have a great, great concern that we are not
seeing enough minority representation in programs that are
currently being administered by the Department of Labor. And I
have taken a strong approach to see how we can integrate this
goal in any type of guidance that is being provided, especially
for funding that is going to be made available within the next
month. And I am talking not just about the summer youth
employment programs, but I am talking also about the
opportunities through green jobs and through the health care
industry. We have several programs that help to provide
incentives.
One of the things that I am trying to cast here is that we
provide stakeholders who have traditionally not been a part of
the makeup of these organizations and infrastructure that we do
our best through our reasonable offices to contact these local
CBOs, these various faith-based groups, various nontraditional
groups that have not been a part of the discussion. And that
has been a very clear signal that I have given to my staff, as
well as any correspondence or speeches that I am making out in
public. So I have the highest concern that you do. It is
unacceptable to have a 15 percent unemployment rate for African
Americans and over 11 percent for Hispanics. And we
traditionally see that cohort continually being affected when
we are in recessionary times, and we have to turn that around.
So I know that we have much to do and we have to prove that
these programs can work. So I will be very diligent in how we
administer the money, that it is accountable, and it is also
transparent.
JOBS IN MANUFACTURING
Mr. Jackson. We seem to be the last hired and the first
fired in difficult economic times. And so any attention that
your administration and your Department could give to these
troubling statistics would be helpful. Let me try and formulate
another question. I spoke this weekend at the college
commencement of Lincoln College in downstate Illinois.
Approximately 194 graduates at Lincoln College this past
weekend. 2 million college graduates will graduate during this
graduation season from colleges and universities across the
country. And I found this year's commencement address to be
particularly difficult to deliver in part because at least for
me, the economic outlook for those students entering the
workplace is profoundly troubled by the highly competitive
nature, the fact that so many Americans with college degrees
have been laid off, have been displaced, have suffered during
the economy. That as these students leave college at one level
or another optimistic about their hopes and about their
chances, they are also entering probably the most competitive
job market in a generation. That does not include the millions
of high school students who are graduating, many of whom will
not attend college, but also enter the workforce looking for
jobs.
My question turns, I think, on manufacturing. It was
brought to my attention this morning that there is a Ford
plant--and as you well know, Ford did not take advantage of any
of the Federal bailout moneys for the automobile industry--
there is a Ford plant in Brazil that makes four different
models of Ford. Not a single model touched by a human hand from
the beginning of the car to the completion of the car. Not a
single model. The plant is so modern that they have to change
nothing to produce different cars on the exact same assembly
line. That is, they do not have to stop making the Ford Taurus
to produce a Ford F-150. An F-150 can be there, a Taurus can be
there, another car can be there, and four different cars on the
exact same assembly line. I realize that my time has expired.
Can you quickly tell us and share with us the
administration's thoughts on what we are going to do to try and
save U.S. manufacturing jobs here in the United States? Thank
you, Mr. Chairman.
Secretary Solis. Thank you. I will try to be brief. But I
think one of the urgent matters right now is trying to provide
assistance to dislocated workers. And we have been doing that
through the National Emergency Grant Program as well as through
the dislocated worker program. That program, as you know,
provides assistance to people who are unemployed, but it also
provides a safety net. It also allows you to get training. It
also allows you, in some cases, to get health care. I have just
returned yesterday from Michigan, visiting a battery plant that
is going to be producing batteries for the new latest
electrical vehicles. Most of the equipment that I saw that was
needed there was imported.
That is another area that we have to focus in on, on
providing a workforce that can create and manufacture the
supplies, and also the educational wherewithal so that we can
produce these cars that many in the public want. We are making
a tremendous investment here. We know that things are not
looking good. We know that it is not just about statistics, it
is about real people that are not able to make home payments,
cannot send their kids to college, and do not have any luxury
of finding a good job at this time. We are promoting that by
providing incentives. I know we are working in collaboration
with the Department of Energy right now as they give out monies
for research and development in these high-tech, renewable
energy areas.
We then couple our programs for training so that we can get
the up-skills available for those people that are off the
assembly line from the auto industry, or perhaps they have been
working as a banker and they need to look at an entirely
different career. This is going to take a lot of courage on the
part of the public as well as this administration to try to
move folks in a direction where there will be job growth. We
did not talk a whole lot about health care, but that is one
additional area of growth, as well as IT, and obviously the
renewable energy industry.
Mr. Jackson. Thank you, Madam Secretary.
Mr. Obey. Mr. Lewis.
JOB TRAINING DOLLARS
Mr. Lewis. Thank you very much, Mr. Chairman. Madam
Secretary, Southern California has been particularly severely
hit with unemployment. You and I have experienced that in our
home districts. The region of the Inland Empire suffered as
greatly as any section of the country relative to housing
foreclosures in no small part because of crazy housing policies
developed by Democrats and Republicans over a 30-year period
that really kind of forced the marketplace with our goal to
have everybody have a chance to buy a home. But as the
marketplace changed, we found people going into homes they
never should have been in in the first place, they could not
afford them. And in the meantime, the vacancy is there. And I
understand that there are still hundreds of billions
potentially of dollars of homes that could be in a very similar
circumstance.
So that problem and its impact on unemployment is going to
extend itself over a considerable time. As we go about trying
to train and retrain those people, I certainly do not have any
bias myself about green job advocacy. I think you may know I
sponsored the Air Quality Management Act in Southern California
years ago. In the meantime, though, my local Workforce
Investment Boards are saying in our region, looking at the
unemployment problem, being forced to push money or training in
the direction of green jobs could very well have us spending
dollars in a direction where there really is not the problem
and will not solve the relatively short term circumstance for
these communities.
So the question they are asking is, is it feasible to have
more flexibility and giving the local communities a stronger
voice relative to the way those job training dollars will be
applied?
Secretary Solis. Thank you very much, Congressman Lewis.
That is a very good question. I do believe that there is enough
flexibility, at least in the guidance that we are going to be
providing, to allow for that growth in the green collar
industry, but also to provide assistance for those folks that
maybe need an additional skill, maybe an IBEW worker, an
electrician or a plumber wants to now better understand and get
into wind power and help develop that industry, or perhaps just
upgrade their skills, maybe entering into an apprenticeship
program or a community college program.
I believe the regions do have the ability to control where
monies can be sent, and certainly would want to hear what their
greatest concerns are. I do not think we necessarily need to do
that from Washington, D.C. I think that we have to attack this
program on a regional level and want to see discussions about
that. As we are seeing the automobile industry being affected,
you are talking about regions across the country where workers
are being dislocated. California, it is the hotel-restaurant
industry, it is the service sector, and we ought to be looking
at how we can be flexible to make that arrangement. So I am
willing to work with you on that, and I believe our
administration, our President is very open to that.
IMPACT OF RECOVERY ACT MONEY ON PROGRAMMING
Mr. Lewis. Thank you very much for that response. Madam
Secretary, the stimulus package has caused many an agency
suddenly to find themselves awash in money, with a good deal of
flexibility given to the directors, and yet that leads to a
tendency to want to expand programming. And clearly you are
expanding programming. If the levels that the stimulus raised
us to in many a sector are not reflected with a similar level
of growth from the 2009 to the 2010 years and the 11th year and
the 12th year, will that cause serious impact upon your agency?
Have your people helped you to begin to evaluate that question?
And I would appreciate first your responding, but then beyond
that, responding further for the record.
Secretary Solis. I think, Congressman Lewis, you bring up a
very good point, because we realize that the Recovery Act money
is somewhat of a one-time opportunity for us. And we have not
seen this unprecedented level of support. But by way of saying
that, it is very important that the programs that we have
funded through the recovery program where we were able to make
some initial funding and growth and expansion in dislocated
worker programs and also the other programs that provide
assistance in the UI program because of the tremendous
unemployment, the financial crisis, there was a need to provide
that safety net. However, in upcoming fiscal budget rounds, I
am certain that we are going to see some tightening of the
belt. And I am sure that we will be looking at programs that
have not worked efficiently, and where we can find and cut down
on any type of fraud or misuse of funds. I believe in
competitive grant making as well. I do not believe that anyone
should have an opportunity to sole source a contract out. I
think the public spoke very clearly about that to many of us.
Mr. Lewis. Secretary Solis, I have other hearings going on,
so I am going to have to run in a while, but in the meantime,
congratulations on your new assignment. And I look forward to
working with you.
Secretary Solis. Thank you very much.
Mr. Obey. Mr. Moran.
PUBLIC TRANSIT BENEFIT AT DOL
Mr. Moran. Thank you very much, Mr. Chairman. I will try to
continue to get here early. I appreciate the incentive. Madam
Secretary, a few years ago, I put a provision into the bill to
encourage people to use public transit in Federal agencies. It
was a public transit benefit of $100 a month. Every Federal
agency embraced it but one. And that particular Secretary said
that all of her employees were eligible unless they joined a
union. But if they were a member of a Federal employee union,
they would not be eligible to receive any public transit
benefit. Of course, that being the Secretary of Labor, I found
it somewhat ironic. Now, I understand that you fixed that. That
is the question. I trust that everyone is eligible whether or
not they join a Federal employees union?
Secretary Solis. Yes, Congressman Moran, thank you for your
question. And yes, we have made that available to our
employees.
WIA REAUTHORIZATION
Mr. Moran. Thank you. The second question, I hate to be
parochial, but you know, we all have to deal with our own
economic situations. In the BRAC closure, the Base Realignment
Closure of 2005, Arlington County lost 17,000 jobs that were to
be moved out. That is the equivalent to four major military
bases. And there is a program in the Department of Labor that
is specifically designed to help with relocation. There are
emergency grants that are made available. And but that money
was not made available until December of 2008. In other words,
just a few months ago. And now I understand that you have
decided to terminate the program this July.
So in other words, there would only be a period of six or
seven months where the money might be available, but all of the
people have to move out by 2011. So this is the time, the
fiscal year 2010 budget, when the money would be most needed.
So I wanted to ask you about that. Can we get an extension or--
it just seems as though the timing is not particularly
consistent with the demand that all of these people be moved
out of the community.
Secretary Solis. I realize that many of our States are
going through this readjustment, and to be honest, this is
something that is inherent in the legislation. It is part of
the formula that is actually made available by Members of the
House. They set that schedule for the formula for the
allocation of these funds that you are talking about. And we
are finding that while your State may have been hit hard
earlier, before the recession, obviously 2 or 3 years before,
now that we see other States coming on board with very high
unemployment rates, that money is not as easily available at
the same amount that it was to prior years. I do believe that
we are making every effort, though.
We do have a contingency fund of about $200 million for
dislocated workers. And we also have revenue, I hope that will
be approved by this committee, to the tune of at least $71
million that can also be available to help with the dislocated
worker national reserve money. So there will be, I think, our
ability to make these kinds of adjustments. And I certainly
will want to work with you and your staff on this. But know
that I too am well aware that we have a problem, and I hope
that this might be something that could be taken up when we
reauthorize the WIA reauthorization.
Mr. Moran. Thank you, Madam Secretary. So in other words,
you are saying we found the source of the problem, and it is us
rather than you. I cannot say I am surprised at that. Thank you
very much. I know so much of the Department is mandatory in
origin given the authorizations. Very little of it is actually
discretionary. I hope we can fix that imbalance a little bit,
give you a little more discretion to meet the specific and the
most intense needs around the country. But again, it is very
nice to have you as Secretary, and thank you, Mr. Chairman.
Mr. Obey. Mr. Cole.
H-1B AND L VISA FRAUD
Mr. Cole. Thank you very much, Mr. Chairman, and let me add
my congratulations. It is always a great thing when somebody
from our body goes to the other side and can explain this to
one another. You mentioned in your written testimony that the
administration was going to be seeking changes in the H-1B and
L visa fraud prevention fees, statutory changes. And I have two
questions along those lines. One, could you acquaint us to what
the nature of the changes are going to be? And two, as somebody
that frankly favors raising the limits on H-1B and H-2B visas
in terms of the numbers of people that we allow to come into
the country, are you comfortable you are going to have what you
need in terms of enforcement and fraud if Congress does indeed
at some point raise those numbers?
Secretary Solis. I would like to answer the latter part of
the question first. We are going to, I think, be diligent in
seeking a better assessment of how the program is operated
because we know there have been abuses. And I think that is the
number one. We want to make sure that we get to those bad
apples. And that sends a signal, right there. I think also we
want to do an evaluation to make sure that we are actually
assessing the area most impacted, if we are, in fact, doing our
best to inform American workers who might be eligible for these
jobs. That is one of our priorities that the President and I
both have. So we want to do what we can to help make sure that
there is ample information, that those surveys are reflective
of the working pool that is available, and then begin, if there
is more need, to have further discussion and have a bigger
debate with all the stakeholders.
Mr. Cole. Okay. And can you tell us what the nature of the
changes are going to be in the easing of the statutory limits
on the using of the fee at this point?
Secretary Solis. I think it is somewhat premature at this
time, but I will certainly get back to you on that.
SENIOR COMMUNITY SERVICE EMPLOYMENT PROGRAM
Mr. Cole. Thank you. I appreciate that. Secondly, I am very
pleased to see your efforts to expand expenditures in
YouthBuild. I am a little concerned that we are not seeing a
comparable increase in Senior Community Service Employment
Program. That is a great program. And I think you are going to
see, frankly, sadly, more need for that program in the current
economic teams. We have got a lot of people who are being
forced out of jobs early in their 50s and 60s, and they are
going to need some sort of bridge to retirement, or people
again that just simply need the supplemental income, they are
post-65. Are you comfortable we have got what we need there?
Secretary Solis. Well, I know that the recovery program did
give us a bump up, and that was helpful. But looking into this
next program year, fiscal year, it is going to be a challenge.
And I know the chairman and I have spoken about this. I have a
strong commitment and support to our senior citizens and our
elder population. When you think about it, in a short time we
are seeing so many people that have been displaced. They are
55, 60 years old even, and we are seeing a larger number of
people who really do need this kind of program. I have seen it
work very effectively in my own State in California. In East
Los Angeles, there is a health program actually that helps to
retrain seniors.
I met a woman that was 77 years old who was a bookkeeper.
Spoke Spanish. But it was tremendous that she was able to have
that as her fulfillment and extra earnings that she could have.
So I do want to enter into that discussion with the committee
members. And I am very, very pleased to hear that from you,
Congressman.
Mr. Obey. Would the gentleman yield?
Mr. Cole. I certainly will, Mr. Chairman.
Mr. Obey. Let me simply say to the gentleman that I think
he can count on that program being one of the programs that
receive a bump up when we get to markup.
PENSION BENEFIT GUARANTY CORPORATION
Mr. Cole. I appreciate that, Mr. Chairman. I am glad to
hear that. Because it is a great program. Let me ask you
another area where I am a little worried that we may have
undershot rather than overshot is the Pension Benefit Guaranty
Corporation. Again, I think we are going to see a lot of
pressure. We are already seeing a lot of pressure on that. And
there is nothing worse than being at retirement age and all of
a sudden losing--you do not have the time horizon to recover.
So are you comfortable you have the tools you need to make
sure that when companies have guaranteed workers pensions that
they have got the wherewithal to back up the commitments they
have made and you are sort of on top of it and able to monitor
it?
Secretary Solis. I think that this is one area where the
funding for this particular program has been somewhat stable.
We have not seen the dramatic decreases, as we did in
enforcement in other agencies in the Department. I do think
this will be an area that will be of continued concern as we
see big corporations going under and the effects that it will
have, and really getting more staff involved to help look at
those cases where there is fraud or where there has been
embezzlement or things of that nature. I think at this time, we
are prepared to kind of stay the course where we are. But when
it is appropriate, I would like to have those discussions with
you and with other members of the committee.
Mr. Cole. I see my time is up, Mr. Chairman. So I will hold
for later. Thank you very much, Madam Secretary.
Mr. Obey. Ms. DeLauro.
OPPORTUNITIES FOR WOMEN IN THE WORKFORCE
Ms. DeLauro. Thank you very much, Mr. Chairman, and
welcome, Madam Secretary. What a joy, what a joy. We miss you
here. We all feel that way. But we are so delighted that you
are at the helm of this Agency, because we know at your core
about your concern and your caring about what is happening with
working Americans, and also the balance that you spoke about
before between workers and business in order to create the best
environment and atmosphere so that people will have jobs and
businesses will be strong. Your budget makes it clear that this
Department is in capable hands, and that there is a kind of a
renewed sense of purpose at this Department.
And we want to help people build their skills and face a
recession with the assistance they need. I will make a point
and then get to my questions. I, for one, am so delighted to
see what you are done at the core of your mission with worker
health and safety. The funding increases for regulatory
enforcement agencies such as OSHA, Wage and Hour, Office of
Federal Contract Compliance Programs. For too long, my view, we
have had a group of folks that relied solely on voluntary
compliance.
And it is fair to say that with this budget that those days
are over. Let me kind of frame my one question, but it is with
3 pieces. I have a concern with the Recovery Act and a fair
chance for women in their employment, and I think we need to
find ways to ensure women, minorities, economically
disadvantaged job seekers are provided with equal access to
training. So first question, and I will give you the other two
and then let you answer. Given the number of new jobs that are
going to be created, how do you see the role of the Office of
Federal Contract Compliance in ensuring that the contractors
who received Recovery Act funding have a plan, a concrete plan
to recruit, retain women, people of color, veterans, and people
with disabilities?
How would the funding be used to create guarantees so that
we are not going to be with the contract compliance office of
identifying contractors who have not done enough of a good job
after the fact, that is after they have the money to do that?
So that office. Secondly, with regard to the Women's Bureau, I
think women are--this is a tough recession for everyone. I
think women are the hardest hit. There are circumstances
undergirding all that is they are paid $0.78 on the dollar. But
the hidden gem, I think, at the Department of Labor is the
Women's Bureau. We know from this committee that the prior
administration tried to weaken it, ultimately tried to
eliminate it, and this committee prevented that from happening.
Let me ask you this: How you see the role of the Bureau as
we move forward. Personally, I would like to see the funding
doubled, but that is me personally. But I think it is a
powerful agency. And if you could just give us some insight
into how you plan to reinvigorate that.
Last piece of this question is, I do not know if you are
familiar with the Pathways Advancing Career Training
legislation. And you probably are. The PACT Act. It is
Congresswoman Linda Sanchez, Jared Polis, Mary Jo Kilroy, and
myself. This would prepare women for employment in high wage/
high skill fields. My hope would be that with regard to the
Women's Bureau we would be willing to open a dialogue about how
the policies can be implemented both under current law and as
we consider new legislation. Let me ask you to respond.
Secretary Solis. Thank you, Congresswoman DeLauro. It is a
pleasure to be here with you. And I know you understand my
personal commitment to women, having served on the bipartisan
Women's Caucus with your leadership and so many members of the
committee here. I continue to feel the need for us to move the
Department of Labor so that every aspect of our agencies
reflect not only the goals of achieving better representation
for women, but making sure that there are opportunities at
every level. The Women's Bureau, for example, is one part of
that. But we should have a seamless system where if OFCCP has a
mandate and guidelines set forth, where they are following
through on making sure that there is nondiscrimination
occurring with protected classes and groups, but also women.
And we are looking at pay equity. That is something that we
are going to require a lot of help on. I think the Women's
Bureau can play a role there, helping us to gather the data
that are going to be necessary, because there is going to be a
lot of Federal contracting opportunities. Here is our chance to
open up that door and have better relationships, but also let
people know that this is a priority of the Federal Government,
and DOL will work with them on that. In terms of Office of
Contract Compliance, I know there are many issues there. We
have not been as diligent as in the past.
And I have not yet identified our leader for that
particular position. We are interviewing now. So I hope to soon
have someone who will lead that charge. And you know from
personally working with me that I am very, very concerned about
making sure that there is equal representation with respect to
Federal contracting. With respect to the Women's Bureau, I,
too, want to see a more robust program there. They will be
involved in helping us identify women in nontraditional fields.
We just had a roundtable a month ago with 35 women from around
the country to talk about the notion of green jobs, whether it
is in high-tech, and whether it is other low level
apprenticeship programs, community college, and women who are
just entering the workforce after leaving TANF or welfare.
So there are many, many opportunities, and I can see us
working very closely with you. With the last item you
mentioned, the PACT Act, I believe that was introduced before,
and I think I had supported it. And certainly the concept is
something that I know has to be something that we need to be
involved in.
So my office would work very closely with you on providing
any technical assistance and information that you need to help
support your legislative agenda in that respect.
Ms. DeLauro. Thank you and congratulations.
Mr. Obey. Ms. Roybal-Allard.
CHILDREN IN THE WORKFORCE
Ms. Roybal-Allard. Thank you, Mr. Chairman. And welcome,
Madam Secretary. Let me just associate myself with the comments
that were made by Rosa DeLauro and others about how pleased we
are that you are at the helm of the Department of Labor,
because we know of your commitment to the working men and women
of this country. And I know that one area of concern for you
has always been the children in the workplace. And I would like
to bring your attention to the plight of children in
agriculture. While only 8 percent of children work in
agriculture, according to a Human Rights Watch study,
approximately 40 percent of all workplace deaths, and nearly
half of all workplace injuries suffered by children occur in
agricultural jobs.
And unfortunately over the past few years, little attention
has been paid to these children by the Department of Labor. For
example, of the 1,344 child labor investigations the Department
undertook in 2006, only 28 were in agriculture. Do you
anticipate increasing investigations into the injuries and
deaths of these children? And will the Department increase its
oversight of children working in agriculture?
Secretary Solis. Thank you, Congresswoman Roybal-Allard.
Yes, as I mentioned earlier in my testimony, we plan to have I
would say a very robust Wage and Hour enforcement. And that
also lends itself to providing more inspections in this area.
I, too, am very saddened by the number of investigations that
have not occurred, quite frankly. And this is an area that we
do need to focus in on. And I do know that there need to be
more opportunities for our young farm-worker youth. And there
are incentive programs available to help them with that. We
hope to expand that. I hope to work very closely with our
regional offices to make sure that they go out, identify those
programs that have the capability of taking on this project,
but also knowing that we have to have good enforcement and good
data to report so that you send a signal that this is something
that will not be tolerated.
Ms. Roybal-Allard. Madam Secretary, I will be introducing a
bill known as the CARE Act in June that extends the same child
labor protections afforded other children to the 400,000 youth
working in agriculture, who are four times at risk of fatal
injuries than children working in other industries. And I look
forward to working with you as that bill moves forward.
PROTECTION OF HEALTH CARE WORKERS IN THE EVENT OF A PANDEMIC FLU
For several years, health care workers have petitioned OSHA
for an enforceable standard to protect health care workers in
the event of a pandemic flu. And this standard would require
hospitals to provide respirators to protect hospital workers
while they treat sick patients. The CDC has warned that it is
simply a matter of time until we face a pandemic flu. And the
H1N1 flu reminds us that that threat is real. Will your
Department direct OSHA to issue enforceable guidelines to
protect hospital workers in the event of a pandemic flu? And
what steps will the Department of Labor take to ensure that our
Nation's health care facilities have in place enforceable and
appropriate standards for infection control and respiratory
protection?
Secretary Solis. Thank you, Congresswoman. This is a very
timely question, and one that just a week ago or two we had a
discussion with our internal office, OSHA, and they have
prepared discussion points and guidelines to work alongside
with CDC. We know that the respirator option here, wearing what
they call an N 95 respirator is what we would want to see occur
for health care workers. It provides better protection for
them.
Typically, the masks that you see being used right now, for
example, do not prevent someone from being contaminated with
the H1N1 virus, or any virus. So that is, I think, a better way
of moving towards that protection. We are coordinating with all
the other agencies in terms of getting out our directives so
that we can protect all the workers that are providing
services, that are front line workers, first responders, and
obviously health care workers. So we are doing our best. It is
something that I know that we do have addressed in our budget.
I know the President has an additional request for money there.
And I think we are satisfied with that amount that he is asking
for.
WAGES FOR JOB CORPS INSTRUCTORS
Ms. Roybal-Allard. Okay. As you know, the Job Corps
program, which provides at risk youth with critical
occupational and employment skills, relies on a cadre of
dedicated teachers. However, the Job Corps instructors are paid
on average 30 percent less than public school teachers, even
though they have the same credentials and are required to work
year round. And this makes it incredibly difficult for Job
Corps centers to recruit and retain the staff needed for this
important program. And unfortunately, after several years of
flat funding, Job Corps, I understand, faces a $127 million
operational shortfall, and there is not enough money,
unfortunately, in the President's budget to provide the centers
with the resources that they need for the staff. Do you have
any plans to review this issue and to find ways to address the
high turnover rates and the recruitment difficulties that
plague the Job Corps program given the fact that, you know, we
understand that there is not enough money to make up what is
needed to retain the teachers?
Secretary Solis. Thank you, Congresswoman. I know that, you
know, I came into the budget process when things had already
started, when I finally was able to begin my work at the
Department of Labor. So much of what was said in the budget was
already agreed to. I know that the next round of discussions on
the budget, this is an area that I will want to focus in on.
And I am glad you are bringing it to my attention at this time.
And I have asked my staff to look into it to give me an
assessment. And once we do have a reordering also of where Job
Corps will be. Currently, it was in the Secretary's office. We
plan to put it back where all the employment training youth
programs are. That is where it should be. It is a fine program.
And congratulations, I know that we are going to be breaking
ground in Los Angeles for the Job Corps facility there. And we
should all be very proud of that. But I do intend on working
with you and others to make sure that we are accurately paying
satisfactorily the wages that are due to the instructors.
Because they also provide a very meaningful part of the program
so that these young people who need remedial education or other
assistance get and are able to have qualified teachers get the
pay that they deserve.
Ms. Roybal-Allard. I want to thank you for your help and
support in the Los Angeles Job Corps program.
Mr. Obey. Mr. Honda.
Mr. Honda. Thank you, Mr. Chairman. And welcome, Secretary
Solis. It is a proud moment for those of us who have known your
work and followed your history, too.
Mr. Obey. A California conspiracy.
EDUCATIONAL SYSTEM INVOLVEMENT
Mr. Honda. Actually, it is our class also. And so they say
that the budget is a reflection of our values. And certainly
this budget is clearly quite different from the past
administration's budget. And some comments have been made as to
the increases in certain categories from one budget to another.
And I think that it is worthy to note that some of the high
increases are a result of great cuts that were experienced in
the past. So this is about catching up also. So I appreciate
your great work. And also some of the comments that you made
about the kinds of workers, kinds of employees that the
Department will be employing to work with the community,
multilingual, culturally sensitive, things that will make the
Department more amenable to the communities that we serve.
So I just wanted to share that with you. I also wanted to
extend a personal thank you for your staff's swift attention to
all the inquiries that were sent by my office to your
Department. You know, my district has a significant lack of
middle skilled workers. In the budget justification, you
mention the ETA will be strongly encouraging the one-stop
centers to take an expansive view of how to integrate the funds
into the training system. Can you elaborate on some of the
innovations local one-stops have proposed or ideas that the
Department will be implementing to fill this kind of a need?
And how will these ideas and efforts work with the community-
based job training grant programs?
Secretary Solis. Thank you, Congressman Honda. It is good
to see you. I understand your frustration with the past
practices of these programs. And I am also looking forward, by
the way, to working with individuals on the appropriate
committees to help reauthorize WIA, because we know that there
are some structural problems, and the fact that there may not
be enough flexibility. And that has impeded, I think, the
ability for stakeholders that you just described from actually
being a part and participating in these programs. So what I am
doing now, through the funding that is going out for the
Recovery Act, is setting forth guidelines that say that we have
to involve CBOs, community colleges, and that we should also
look at other educational institutions and higher education as
well. It does not just stop with the community colleges.
There is a role for every part of our educational system.
We have a need for, for example, maybe more literacy for
different segments of our population. The adult schools can do
a good job there. We may have a need for allied health careers.
That too I can see being fulfilled by a community college. But
yet we also have a shortage of folks that are really prepared
in the higher skill levels. So we need to also make sure that
four-year universities are a part of this discussion. And I
hope that we can generate regional support so that we look at
the program more as something that we can solve on a broader
level as opposed to just one source of funding going to one
center. It should be a collaborative effort given that we do
not have a lot of funding available from all these other
streams. We are going to have to work collectively. So that has
been my priority.
INDUSTRIES WITH POTENTIAL FOR INVESTMENT AND GROWTH
Mr. Honda. And we will look forward to doing that. Our
city, San Jose, has made a serious effort to make itself the
greenest city in the United States. And it just received a
platinum certification. And the city has also partnered with
local labor organizations like Working Partnerships USA to
develop green jobs, programs that provide good paying, secure
employment for workers. How is the Department going to foster
and support partnerships like this through the Green Jobs
Innovation Fund? And what are some of the primary industries in
which you see significant potential for investment and growth?
Secretary Solis. Well, I know that we have a very ambitious
program to provide and expand weatherization in partnership
with the Department of Energy. And one of the things we want to
target there is the fact that after you complete your
certification for weatherization that you also be in a program
that can allow you to grow, to get another step up into another
career if possible, or the same career but more expansive
responsibilities.
There has been a lot of discussion with some of our friends
who work in that industry, and also some of our apprenticeship
programs that offer that. We want to make sure that whatever
opportunities are available that we really do kind of cross, I
do not want to say cross-pollinate, but really get as many of
those stakeholders involved that really have not had that
opportunity to expand. And there is a lot of great
demonstration programs out there now. We will be looking at
those as models, and hopefully using our funding in a way that
we can provide incentive to people to follow suit and use those
as models that we can hold up.
Mr. Honda. Very quickly.
Mr. Obey. The gentleman's time has expired. I am sorry. Mr.
Ryan.
WIA REAUTHORIZATION
Mr. Ryan. Thank you, Mr. Chairman. Welcome, Madam
Secretary. It is great to have you here. I have a couple of
questions and a couple of comments. As far as the questions go,
some of the WIA dislocation or dislocated worker money, it
seems like the formula, and we had dealt with this with
demolition money, where States who have been having problems
for a long time, Ohio being one of them, losing their
manufacturing base, the formula is tilted towards States who
have had recent decline because of foreclosures. And States
like Ohio are going to get a 30 percent cut, where States like
Nevada are going to get a 135 percent increase. So we want to
work with you on trying to fix this, because Ohio has been
dealing with this for a long time, as a lot of other industrial
States have.
So we want to try to fix that formula. And also we know you
have some ability with the national emergency grants. And one
of the issues that if you can just comment on this, we want to
work with the Department on States like Ohio having a little
more flexibility with those kinds of grants. Because they are
very specific towards a specific industry or a specific
business. So is there a way we can kind of work through this
where if you do get the emergency grants there will be a little
more flexibility for the States to work with the Department?
Secretary Solis. Thank you, Congressman Ryan. Earlier I was
asked a similar question, and there is a problem I believe with
the formula that drives the funding. And it is unfortunate that
it does penalize States like yours that have been going through
high unemployment and dislocation of workers for a long time. I
know that this is something we probably want to work on as we
go through to reauthorize WIA, which I hope we can do this
legislative session.
Meanwhile, there is some Dislocated Worker National Reserve
money available at the Department of Labor that is in the
amount of about $200 million that we can work with your State
and work with those officials there, because this has been
brought to my attention by one of your Senators already. And
likewise----
Mr. Ryan. I wonder which one that was.
Secretary Solis. And likewise, we do have, hopefully,
through our request here for the 2010 budget, we are requesting
an additional $71 million for the national reserve for this
particular effort. There has to be a better way, though, of
dealing with this financial crisis, because it is longer, it is
more persistent, and I do not think anybody has seen anything
like this for several decades. And there probably has to be
some rethinking on how we do that. So I would love to be able
to talk to you about that.
NEW WAYS OF ADDRESSING OLD PROBLEMS
Mr. Ryan. Great. I wanted to reaffirm that position as far
as the formula is in and working. I have a couple of ideas. I
think that you are new and you are from this body, and we have
a new President, and I think we have to start looking at new
ways of addressing some old problems that we have. I will give
you an example. Our area we have a lot of auto in Youngstown,
Ohio, a lot of Delphi workers. And a lot of Delphi salaried
workers as well. And when Delphi hit tough times, we had a lot
of engineers, we had a lot of tool and die workers who were in
the area. And I know we have to try to retrain and move people
into other jobs, but there is a talent pool in some of these
communities.
In Ohio, Dayton and Warren have a lot of Delphi workers, a
lot of engineers. I think we need to have a conversation and
talk about how we not retrain some of these workers, but how to
get them involved in creating new employment, how to plug them
into incubators, how maybe the Department of Labor and maybe
the Small Business Administration can create incubators in
areas where there is a high talent pool that necessarily will
not go and become nurses or get trained in a green collar job,
although they could, but they are very talented, they are
engineers.
So they could realistically start a company at some point
with a little bit of assistance that would employ 50 people.
And so I just wanted to throw that out at you just so we can
continue to have a conversation maybe over the next few months
and few years on how maybe we can put something together that
would be innovative, but yet tap into the kind of talent pools
that we have in some of these regional areas. And then another
comment, as my time is running down, along the lines of
YouthBuild, there has been a tremendous success in this country
with the FIRST Robotics program. And we see kids in high
schools gravitate towards the robotics program. And it changes
their whole perception and their whole approach to education.
You know, instead of teaching them physics and all of the, you
know, more sophisticated, having all the more sophisticated
classes, that teachers throw a bunch of junk on the ground and
they say build a robot.
And then they build the robot and then they teach
afterwards. And it is just a different way of learning. And we
have had some kids in some of our inner city schools who have
just gravitated towards this. They got to kick them out of the
schools at 10 p.m. So I think as much as YouthBuild is for
construction, I think we should also talk about in the future
about implementing some kind of robotics programs.
Mr. Obey. If you want to respond very briefly.
Secretary Solis. I am glad you brought up YouthBuild,
because we do have guidance to promote green jobs, but not
necessarily the way you described it. We certainly want to have
more math and science applied, and that can certainly help with
this population. So I am very much in agreement to allow for
that creativity to occur, and we would be interested in seeing
those kinds of programs develop.
And then, secondly, I just want to tell you that, through
our office, the recovery of the auto communities and workers is
headed now by Dr. Edward Montgomery. He has been out I think in
some of the different States that have been more dramatically
affected by the downsizing of the auto industry and certainly
will be helpful and I am sure will make himself available, as
well as I, to see how we can try to provide that assistance so
that that talent pool, that brain trust that we have does not
leave and that we nurture it and that we do do some creative
programs with SBA. We do have some training programs, too, for
small businesses.
So those are some things that I am very excited about
working with you on, because I have not seen that kind of
support in the past.
Mr. Ryan. That is great.
Mr. Chairman, if I could just comment on that.
In these old----
Mr. Obey. Very briefly.
Mr. Ryan. Very briefly.
In these old industrial areas, you know, all the young
people have left. They went off, they got educated, their
parents had good-paying jobs, they went off to school, and they
left. So the only talent pool left were in those industries,
the Delphis of the world, the auto industries. So I think it is
critical that part of this comprehensive program is to try to
keep that talent in that area, in that geographical area.
So thank you. Thank you, Mr. Chairman.
Mr. Obey. Mrs. Lowey.
Mrs. Lowey. Thank you, Mr. Chairman.
INCREASING TRAINING OPPORTUNITIES IN HEALTH CARE-RELATED FIELDS
And, Madam Secretary, I just wanted to tell you that I
share the enthusiasm of my colleagues; and we look forward to
working with you. Now, not only is Madam Secretary a friend,
but she is also my neighbor. We leave so early, I think you are
still there. Thank you.
I just want to begin by commenting that what we see in our
health care systems in the U.S. in both private and public, we
are facing a widening gap between the number of positions and
the number of qualified applicants to fill them; and nowhere is
this more evident than the shortage of nurses and nurse
faculty. In fact, in 2008, almost 50,000 students were denied
admission to schools of nursing, primarily due to an
insufficient number of faculty.
We agree, I know, that we must create better training
opportunities in the fields with the greatest needs in the
coming years. So if you can comment on the Department's
strategy for increasing training opportunities in health care-
related fields, particularly through the new Career Pathways
Innovation Fund, and what role can community colleges play in
expanding career opportunities in health fields.
Secretary Solis. Thank you, Congresswoman Lowey.
Yes, while I did want to mention that earlier in my
testimony I had pointed out that we did get $250 million
through the Recovery Act to help us with high-growth
occupations--and, obviously, the health care industry is a
prime sector--I do believe there is a lot more we can do.
I think we need to also be collaborating now with the
Cabinet Secretary of Health and Human Services. They also
received a substantial amount of money, I believe it is about
$200 million, to look at health careers and professions; and it
just does not make sense for us not to be able to coordinate.
We know there is a shortage in all, all parts of the country
and particularly when you talk about underserved or rural
areas. So I am very hopeful that we can utilize this money to
look at not just the first tier but also developing the second
and third tier of these career programs.
So we do have to work closely with our 4-year universities,
community colleges to begin with, and then also make sure that
we have the availability to have a classroom, first of all.
Because I am hearing a tremendous amount of pressure being
placed on the community colleges, that they do not have
sufficient funding to open up a classroom and then pay the
instructor or a particular professor there to be able to come
in, because they make more money out in the field than they
would as a faculty member.
That is something that has to be addressed I think at
another level. But, nevertheless, it does impede our ability to
get people into those programs to get trained.
And I have seen some very good programs, but they are very
limited, and of course they are very rigorous. And for minority
people who want to get into these programs, it becomes even
more difficult. And I just feel that there does have to be more
attention placed overall in the health care arena and be happy
to work with you and with the chairman on this to see how we
can expand that area.
Mrs. Lowey. Thank you.
IMPROPER BENEFIT PAYMENTS
I was shocked to learn, despite efforts of States to reduce
improper benefit payments, more than $3.9 billion in
unemployment benefits were paid erroneously in 2008. Now, the
chairman probably recalls, because we have been talking about
this--I have been around here for about 20 years--antiquated
computers, processing systems in various States and within the
Department. As far back as I can recall, we were told that the
computers still do not talk to each other. So you can be on
Social Security, and you can get unemployment benefits. You can
get all kinds of things.
I just wonder whether the budget addresses this problem.
How is the Department working with the States to reduce and
recover improper or fraudulent payments? And as you are just
beginning your important assignment, maybe this committee can
help you and work with you to address the problems of computers
that do not coordinate, do not talk to each other.
Secretary Solis. Congresswoman Lowey, you bring up an
excellent point. It is one that I am very frustrated with
myself. And, again, this is my second month into the job. I am
not even there a hundred days yet. But I am learning very
quickly where some of these gaps are, and I really do want to
work closely with you and with the members of this committee to
see how we can fix those gaps.
Not only the Federal Government has problems, but, of
course, some of our bigger States, New York, California, Texas,
others are having problems with also processing the amount of
paperwork. And we are finding that some systems are 30 years
old, the COBOL system. I remember that as an undergrad, that
program.
But I am just saying that we do need to have funding to
help upgrade our infrastructure; and that is probably one of
the most neglected areas, just like our bridges, when we forgot
to also provide I think the necessary support that is needed to
help our IT system be up to date. Because there is no reason
why we should not.
Mrs. Lowey. Now I see my red light on, so I will not ask
you for another minute. At another time I will like to talk to
you, because I know how passionate you are about the
International Labor Affairs Bureau. My colleague, Ms. DeLauro,
just whispered to me that the worst abuse, the ILA has said in
Agriculture, is in the United States. And so that is something
that we have to work on.
Thank you, Mr. Chairman.
Mr. Obey. Ms. McCollum.
Ms. McCollum. Thank you, Mr. Chair.
JOB OPPORTUNITIES
Well, a lot of the questions have been asked; and it is
wonderful to, as Congressman Honda pointed out, to watch you
blossom and grow. It is great to have someone from our class
that we can now call Madam Secretary.
I think what I am going to do instead is kind of have a
conversation about some things that I have seen out in the
district and the challenge that I think we face as a Nation
gearing up not only to come out of these difficult economic
times but to prepare ourselves to be competitive in the future.
So I am going to start with we know we have got an
unemployment problem. We know it could very likely go up. This
is like the first time Minnesota, because we have such a
diverse economy, has really faced hard unemployment that we
know is going to be extended for a long time. We have high
school students that we want to encourage to stay in high
school. We have high school students that are graduating that
had really no plans about continuing education. We have high
school students who were planning on continuing an education,
but their families are looking at the cost of college or voc
tech school saying, you know, jeez, we are going to have to
pace ourselves a little different doing this.
College students who are going to come on line now who I do
not know how they are going to be recorded in the unemployment
statistics because they have not lost a job, but they are not
going to be able to find a job. High school students and
college students competing with adult workers for part-time
jobs, people underemployed. You know the picture.
But let me tell you about some of the solutions that I am
seeing out there or I see as a possibility.
I was at Arlington High School just yesterday, very diverse
high school. As you know, my district is very, very diverse.
And they have a bioscience program in which one of the
cornerstones of it is students who want to sign up for it can
take this Red Cross class, which then at the end of it they are
qualified or they are certified to be a type of medical helper.
Pays $10 an hour. But, at the same time, those students are
being reinforced with math, science. But it is broken down in
bite-sized chunks that a lot of my new, vibrant immigrant
population sees as a can-do possibility.
So I know there are opportunities in programs like that
happening all over, and on page eight and nine of your budget
summary that you have given us you are talking about you are
going to work with the Department of Education to track
longitudinal studies. So I think this committee wants--at least
I want--to work with you on how we put that together.
Because if you look at the Department of Labor and its
interrelations with the Department of Health for jobs, for
training, as well as for workers' health, the Department of
Education for jobs and training, the Department of Energy for
jobs and training, how do we get everyone around the table
talking so that we can, just as the computers are talking, so
that we are creating incentives and opportunities as we
reauthorize all these different programs? We are not doing them
in silos? So let me kind of close with this.
OPPORTUNITIES FOR YOUTH
Another place I was recently in the district was talking
about volunteering and community service, something that
President Obama is very focused on. There are so many
opportunities out there, whether it is YouthBuild or our Young
Conservation Corps or something like that to do service, maybe
not necessarily be paid for it. We know cities are under a lot
of stress with homes that need the grass cut, neighbors that
need fix-up projects and that in homes. How do we look to
create a youth service corps that creates educational
opportunities, does exactly what Congressman Ryan was talking
about, makes kids excited about learning? How do we help you
with that not only in this budget but future budgets? How can
we help you?
Secretary Solis. Thank you very much, Congresswoman
McCollum. I am really excited that you are excited and that I
am hearing so many enthusiastic voices about things that I know
we have been struggling over for the last 8 years.
Youth are a very, very important element in our recovery
effort. And I am very happy to say that, looking at this new
round of funding that is going out now through the recovery
program, that there is going to be some area for testing. So
new models can also be interjected for students that go through
our summer youth employment programs. For example, we will have
guidance to say that we do want them to focus somewhat on green
jobs, but that does not necessarily mean that it has to stay
there. It can also go into maybe health, as you are saying,
with the Red Cross or working volunteer. The program allows you
to get instruction and also receive a small stipend if you fall
under the category of being disadvantaged.
But I see where you are going, where we have to have more
of a long-term program that is really extended throughout the
year but has an educational component added to it. So I am
working right now, and our staff is, with the Department of Ed,
because we want to try to minimize where there are areas where
we can work together and not duplicate our efforts. But I am
very enthusiastic about the ability to see our young people
really be a part of this growth that we need to see, badly need
to focus in on our youth. Their unemployment rate is way above
21 percent.
Ms. McCollum. Thank you.
Mr. Chair, I think one area in which I am becoming more
convinced than ever that we have missed the boat is we did not
think we needed high school counselors any more because the
jobs were out there and the economy was successful and
everything was going smooth. By not having high school
counselors, we do our economy a disservice, we do our youth a
huge disservice, and I am hearing from parents a disservice,
because they do not know about all the job opportunities that
are out there to even have conversations with their children.
Thank you.
CRITICAL POSITIONS
Mr. Obey. Madam Secretary, let me ask a couple questions.
And, incidentally, because of the time, when I finish my
questions I am going to try to do a 2-minute second round for
people so we can get Secretary Solis out of here as quickly as
possible.
Madam Secretary, you have been on the job for about a
month, as you said. If you look at the Department's roster of
critical positions--Deputy Secretary, Employment and Training
Administrator, OSHA Administrator, MSHA Administrator, et
cetera, et cetera--can you tell me how many of the senior-level
vacancies at the Department of Labor you have been able to
fill? I mean, how close are you to being in a home-alone
situation?
Secretary Solis. Unfortunately, the process has been so
cumbersome that I have had actually just two; and one of them
is here with me today, who is overseeing my Congressional and
intergovernmental relations, Mr. Brian Kennedy.
Mr. Obey. So you are in the position of speaking for the
Department, defending the Department, and so far you have no
lieutenants in sight save one. Is that right?
Secretary Solis. Two.
Mr. Obey. Two.
Secretary Solis. Maybe our colleagues in the Senate will
heed your call and help us expedite.
Mr. Obey. That would be nice.
FRAUDULENT CLAIMS
Secondly, I hope that in whatever meetings you participate
in having to do with fraudulent claims, I hope you will convey
the message to the executive branch that nothing is more
important in budgeting than eliminating fraudulent claims.
Because every single fraudulent claim that is paid discredits
programs that are meant to provide badly needed benefits to the
deserving. And I hope that the administration will put together
a--I do not know, I do not care whether it is a task force or
you name it. Whatever they call it, we need a crash course to
eliminate that nonsense because we just cannot afford it.
RETURNING VETERANS
I would also like to simply say that I am concerned about
the steep rise in unemployment for returning veterans returning
from Iraq and Afghanistan. According to BLS, the unemployment
rate for post-9/11 veterans jumped from 8.9 percent in January
to 11.2 percent in February, a single-month increase of 26
percent. The overall unemployment rate for post-9/11 veterans
is 32 percent higher than the unemployment rate for the general
population.
How is the Labor Department enforcing Federal laws ensuring
that military personnel returning from Iraq and Afghanistan are
able to return to their jobs they left behind?
[The information follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
And what can the Labor Department be doing for unemployed
veterans?
[The information follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Secretary Solis. Thank you, Chairman Obey.
This is of great concern to me as well. Having over the
last 8 years represented a district in Los Angeles with one of
the highest rates of veterans and homeless veterans, this is an
issue that I do not think many of us quite understand how to
get our arms around. But we do have incentives in our budget to
provide assistance for homelessness for veterans but also for
female veterans, because we are also seeing an increase there.
And they face different problems, because many of them may have
children. There is not enough space available at some of these
transition homes, and there is a need for that.
So as we are uncovering and seeing our young people coming
back from Iraq and Afghanistan, we are finding that they have
multiple different types of challenges. But one that I am
charged with overseeing is the fact that if a returning
soldier, he or she, goes to a place of employment that they
previously worked at and are denied that placement, we have an
obligation to go back there and investigate and then file our
complaint. That is something that I hope to beef up, because
there are too many of those reports that are coming out.
And then, secondly, I am trying to work closely with DOD to
look at their programs where returning soldiers are given
appropriate information, not just a one-time kind of drop in
the bucket, of different services or things that they can apply
for but being a little bit more consistent with them and their
spouses. Because the spouses are also an important element
here. And I believe that the President's wife, Michelle Obama,
also has a great initiative there to try to help with our
veterans' spouses and the families.
ENHANCED ENFORCEMENT PROGRAM
Mr. Obey. I just want to make a last point on my time.
In the early years I was on this subcommittee, I worked
with Silvio Conte and to some extent with Bob Michel in trying
to see to it that OSHA was more flexible in dealing with
employers who were generally trying to meet their obligations
to their workers. We worked to do a number of things that
required retraining of inspectors so they quit focusing on the
minutiae and started focusing on the real problems, and so I am
all for the agency being reasonable. But there are also other
kinds of employers who are not at all helpful.
Example, when my sister was dying, at first the doctors did
not know what was wrong with her. Her lungs were filling up
with fluid. They thought she was having an allergic reaction to
something she was working with in the plant. And so they asked
her husband if he could check on the plant floor, because they
both worked at the same place. The doctor asked her husband if
he could check to see what the chemical content was of the
solvent that they were using on their machines. He tried to do
that and was blocked from doing it by the employer, even after
the doctor called and asked them to allow him to check that
out.
So while there are certainly legitimate employers with whom
we need to work, there are also people who put the dollar
bottom line ahead of everything else. And that is why we need
to have an OSHA that performs much better than it has in recent
years, when we discover that the Inspector General showed that
the OSHA enhanced enforcement program was a spectacular failure
because of OSHA's failure to go after employers who really
needed going after.
And, with that, Mr. Tiahrt.
Mr. Tiahrt. Thank you, Mr. Chairman.
CREATING GREEN JOBS
The study that was conducted at King Juan Carlos University
in Spain found out that the European model of creating green
jobs cost 2.2 jobs on an average for every job created. In the
study, they talk about how the government got locked into old
technology in their pursuit of green jobs. And I see that
already in our own government, where we are sort of locked into
solar panels to generate electricity while the private sector
is moving to photovoltaic panels; and they can generate more
electricity. And they are going into parking lots, like in
Phoenix, and getting landowners to allow them to create shade
for their customers, while they put these panels overhead to
create the shade and also generate electricity.
So with the innovation in the private sector and the
tendency for our government to get locked into a technology
that becomes stagnant, what level of job loss does the
administration find acceptable to create green jobs?
Secretary Solis. Well, I look at this a bit differently. We
have had tremendous job loss for the past--what--December 2007,
long before this new administration was here. So this has been
an ongoing issue for some time with high rates of unemployment
that are not acceptable to anyone.
I think that green jobs is not a silver bullet by any
means. I think that there is ample opportunity, however, for us
to begin to invest R&D into research and new science and
technology to help create our security independence away from
fossil fuels and look at how we can use materials and resources
that we have here at hand and be better navigators of those
resources.
The study that you cite I understand was conducted by
industry individuals who feel that there may be a job loss in
their industry. I see this as an opportunity, as we heard a
theme recurring here, is that we have many people who are being
dislocated and displaced--engineers, bankers, people who are
well educated and qualified to do many things. I hope that when
we begin the discussion of looking at new, renewable jobs and
jobs of potential growth that we look at all opportunities. But
I do see green jobs as one of our priorities for this
administration but certainly not the only one.
Mr. Tiahrt. Just to correct the record, the study was
conducted by King Juan Carlos University and Dr. Alvarez. So it
was done by the University and not the private sector.
Thank you, Mr. Chairman.
Mr. Obey. Ms. DeLauro.
Ms. DeLauro. I have a very quick question, Madam Secretary.
DIACETYL
This is about an issue that I have worked on for a number
of years, and it follows up with what Chairman Obey was talking
about, the potential harm that is caused by the chemical
diacetyl to thousands of workers who are mainly working at
popcorn manufacturing facilities. You have taken initial steps
to address the issue, and you have convened a Small Business
Regulatory Enforcement Fairness Panel to look at it. I
understand there is a process in place, including a 60-day
comment period. I want to ask for your assurances that this
will be a priority for the Department and OSHA; and, if so, can
we anticipate seeing a proposed rule on diacetyl in the Federal
Register?
Secretary Solis. Congresswoman DeLauro, I am happy you
brought this item up. It is one that I know I worked on here as
a House Member with other members of the Labor and Education
Committee, and it is something that we are taking very
seriously.
Right now, we are finishing up a small business review
process that has to be taken for diacetyl; and we will soon be
able to move forward with a formal proposal.
Ms. DeLauro. Okay. Thank you. I would like to continue to
work with you on that.
Thank you, Mr. Chairman.
Mr. Obey. Mr. Cole.
Mr. Cole. Thank you, Mr. Chairman.
I know we are operating under an abbreviated time schedule
here, so let me make two points, if I may, and then entertain,
obviously, whatever response you would like.
OFFICE OF LABOR-MANAGEMENT STANDARDS
First, I would like to very much associate myself with Mr.
Tiahrt's remarks about the concerns and the cuts in the Office
of Labor-Management. You know, frankly, most of our money in
the Department of Labor is appropriately spent on protecting
workers in the workplace and mitigating disputes between
employers, et cetera. But labor unions are not always a force
for the good, and there certainly has been plenty of instances
of abuse. And if we ever pass Card Check in this Congress,
potentially you might need more oversight rather than less. So
that does concern me greatly.
Second, while I appreciate the emphasis on green jobs, I
want to say for the record in my State, in Oklahoma, frankly,
the energy industry, the oil and gas industry has provided more
opportunity for more people than any other industry in the
history of the State. Upward mobility, the greatest
concentration of technical talent, the highest salaries are
paid there. We have the number one and two producers of natural
gas in America headquartered in Oklahoma City, and even critics
of carbon-based energy generally recognize natural gas as the
least objectionable of the carbon-based energy sources. So if
we are going to have an emphasis on green jobs, I would suggest
natural gas is one that ought to get an emphasis.
And, honestly, nuclear energy ought to also get an
emphasis. I do not see any way with renewables alone this
country will be remotely energy independent in our lifetime. We
are going to have a carbon-based energy sector. It is going to
be extraordinarily important; and, frankly, we ought to follow
the example of our friends in Europe, particularly the French,
and look pretty seriously at our nuclear-based capabilities,
where I think we have basically abandoned a lead that we had 20
or 30 years ago. They have actually done better than us in
recycling and taking care of the waste products. So I would
hope you look, when you think green, you do not exclude natural
gas and you certainly do not exclude nuclear.
Secretary Solis. Thank you, Congressman Cole.
I would just concur that I think that natural gas is
another source of energy that we should be utilizing more. I
know that might be something that the Department of Energy will
probably undertake, as well as the nuclear energy debate; and
certainly we have to look at what resources we do have here.
Hopefully, whatever takes place, it will be done in a manner
where we can have the cleanest energy provided with the less
egregious outcomes in our communities. So I am with you on
that.
And with respect to OLMS, I would just say to you that they
have had substantial increases in their budget for the last 4
or 5 years, more so than the other agencies; and what we are
trying to do is level the playing field. We will be moving some
of those investigators over to Wage and Hour, where we do need
them, and in OSHA.
Now, there are appropriate skilled areas where there is a
better fit. That does not mean we are going to hold back on
looking at any fraud or misconduct facts if folks are not
complying with the law. So we will be very diligent there, and
I can promise you now that we are already keeping that pace
now.
Mr. Cole. Thank you.
Mr. Obey. Ms. Roybal-Allard.
Ms. Roybal-Allard. Just a quick statement.
MIGRANT AND SEASONAL FARM WORKERS
I have been asked, Madam Secretary, to thank you for
recognizing the value and the contributions of migrant and
seasonal farm workers to our society. This is the first time in
8 years that the job training program for these hardworking
people has been included in the Department's budget. During the
last 8 years, under the leadership of our chairman and his
efforts, we have had to restore the funding for the over 45,000
eligible farm workers who have been trained and placed in
steady, year-round employment. However, as you know, the
funding for the program only permits us to reach a little less
than 3 percent of the eligible population. So my hope is that
we can continue to find ways to increase the funding for this
very effective and successful program so that it can reach more
farm workers.
Secretary Solis. Thank you, Congresswoman.
I would just add that we are trying to, with one of our
notices that did go out, to the workforce investment system to
provide additional information for funds for the national
emergency grant program to be used for this particular
population. So I am excited about that. But I know that we
should have those discussions to further figure out how we can
address the long-term issues here that I know both you and I
are very concerned about.
Mr. Obey. Mr. Ryan.
Mr. Ryan. Thank you, Mr. Chairman.
TELEWORK AND TELECOMMUTING
One question. I know the Secretary of Transportation and
the Secretary of HUD are working together on a Sustainable
Cities, Livable Cities Initiative; and one that I read in last
year's report that the Department of Labor is looking at is the
telework and telecommuting and those kinds of things. So if you
could just comment on your opinion on telecommuting I think
from traffic purposes and the whole greening of our country.
This could be a component to it. So are you going to be
involved in any of those discussions or initiatives?
Secretary Solis. Well, we are collaborating with Department
of Energy and HUD and Department of DOT, and we know that it is
very important to allow for flexibility in the workplace so
that families--and this comes up often with respect to folks
that need to work from home and having that flexibility. I
think that that is a way to go. It saves costs overall,
transportation congestion, but also probably more productivity
on the part of the employee. So I think that those are
mechanisms that, as you have outlined, that are very important
for us to follow up on; and we will be working with our
partners in the other agencies to see how far we can promote
this program.
Mr. Ryan. Thank you.
Mr. Obey. Mrs. Lowey.
Mrs. Lowey. Thank you, Mr. Chair.
INTERNATIONAL LABOR AFFAIRS BUREAU
I referenced before the International Labor Affairs Bureau,
and I know you care very much about it. I am very pleased that
the budget sets the number at $92,000,000, which is an increase
of more than $6,000,000 from fiscal year 2009. This is
certainly a welcome increase, given that the previous President
attempted to drastically reduce this account every year. At a
time when we have taken on greater responsibility abroad, we
have a duty, in my judgment, to do more to improve labor
conditions in foreign countries, including reducing child
labor, protect women's rights, maintain our education in the
HIV/AIDS initiative.
My colleague whispered to me, and I repeated it before,
that the worst abuses around the world are right here in
agriculture. So, obviously, we have to address that; and I know
you will.
Could you share with us how the Department plans to use the
proposed increase to address these priorities?
Secretary Solis. Thank you, Congresswoman Lowey.
You know of my passion and concern for trying to provide
information and data as to what the conditions are with trading
partners in particular, and I think there has been an absence
in this particular division for the last few years. It has not
been a priority. While there has been funding incrementally
provided for the exploitation of children and trafficking,
those are good things that should continue; and I do not see us
minimizing that. But I think now with the new President coming
out with his proposals that he would like to introduce trade
agreements again, it is very important that we do have the best
data available; and I think that we have not had sufficient
funding to allow the Department to be able to get that data, to
work with NGOs, to work with our partners, to also help provide
assistance to our trading partners so they can help hopefully
elevate our standards. That helps American workers in the long
run.
So I do have a vision, and I would like to be able to sit
down when we can to tell you a little bit about more what my
thoughts are.
But I was able to attend the Americas Summit with the
President and met with many of my counterparts from countries
representing Labor Secretary positions, and we had very good
discussions. One of which I heard resoundingly is that they
want to have more assistance from us; they want training from
us as well. They could benefit from our OSHA staff going and
conducting seminars and meetings with them but also importantly
helping them to understand what our labor standards are. So
this is something that is of great importance I know to the
President as well as to myself.
Mrs. Lowey. Thank you very much. I look forward to working
with you.
STATE AID
Mr. Obey. Madam Secretary, let me just make one point in
ending the hearing. The new estimates have come out on the part
of OMB, and they are indicating that we are going to experience
an even larger deficit than we expected. One of the major
reasons for that is because of the drop in revenue into the
Federal Treasury.
And I would point out that the same thing is happening at
the State level. In my own State, just in the last 3 months,
their estimate of the size of the State deficit that they are
going to incur has risen by $1,500,000,000.
The Washington Post this morning carried--and I just want
to read a couple paragraphs--they carried an article this
morning which says this:
Eleven weeks after Congress settled on a stimulus package
that provided $135,000,000,000 to limit layoffs in State
governments, many States are finding the funds are not enough
and are moving to lay off thousands of public employees. And
they tell stories about what is happening in the State of
Washington, Massachusetts, Arizona, et cetera, et cetera. It
says the layoffs are one early indication of how the stimulus
funding could be coming up short against the economic downturn.
As the stimulus plan was being drawn up, there was
agreement among the White House, congressional Democrats, and
many economists that a key goal was to keep States from making
big layoffs at a time when 700,000 Americans were losing their
jobs every month. The House passed a stimulus bill with
$87,000,000,000 in extra Medicaid funding for States, as well
as $79,000,000,000 in stabilization money to plug gaps in State
budgets for education and other areas.
But in the Senate the stabilization funding was cut by
$40,000,000,000 to secure the necessary support to pass the
bill. The article says, supporters of the final
$787,000,000,000 bill, which included $25,000,000,000 less in
State aid than the House plan, said it would help States avoid
severe cuts, but tax revenues are coming in even lower than
feared.
I would simply make the point that, as we discovered during
the Carter and Reagan deficit era, when the economy was going
to pot at an earlier time, we will never balance the budget or
come anywhere close so long as this economy does not get moving
again. With all of the attention that is being paid to the
negative impacts of deficits, I would urge the administration
to remember and remind the country that, at least in the short
haul, the economy needs to be stimulated by those short-term
deficits; and if we do not have enough stimulation, we are not
going to get out of this hole. Because if the unemployment
continues to rise and if we continue to lay off more workers,
those revenues are going to continue to drop, and that is going
to leave us with an even bigger hole than we thought we were
facing.
That can be avoided with the right policies, and I hope
that the administration will recognize that the situation at
the State level is significantly more serious than was thought
at first, as is the situation at the Federal level, and it
requires something more than simply hoping for the best.
With that, I appreciate your coming; and I wish you luck.
Secretary Solis. Thank you, Mr. Chairman.
Mr. Obey. And I hope you eventually get some people around
you on your team so that you do not feel like----
Secretary Solis. I am a one-woman show.
Mr. Obey [continuing]. You are holding court alone. Thank
you very much.
Secretary Solis. Thank you so much, Mr. Chairman, and
members and ranking member. Thank you.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Tuesday, June 2, 2009.
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
WITNESS
HON. KATHLEEN SEBELIUS, SECRETARY, U.S. DEPARTMENT OF HEALTH AND HUMAN
SERVICES
Mr. Obey. Madam Secretary, welcome. We are pleased to have
you here for your first appearance before this subcommittee.
I note the presence of a Kansas cabal. And we welcome that
too today.
Madam Secretary, when I was in the legislature, I served
with a fellow by the name of Harvey Duhall, who is a retired
dairy farmer, homely as a basset hound on a bad day. And he was
probably the best human being I ever served with anywhere.
And one of the things he always said, was, ``Do you know
what? The problem with this country is that all too often the
poor and the rich get the same amount of ice, but the poor get
theirs in the wintertime.''
It is my understanding that you have the outrageous view
that that can change. It is also my understanding that you are
coming in here today intending to do something very radical,
which is to try to provide health care coverage for every
American. I would just like to know where you get that crazy
idea, because it seems to me that we have already seen hundreds
of billions of dollars go out the door to help strengthen
banks, insurance companies, and auto companies under both
President Bush and President Obama. But now, evidently, you
have the outrageous gall to come in here thinking that if we
are going to have socialism for big people, we ought to provide
at least a shadow of socialism for little people.
I don't happen to regard it as socialism, but as you know,
some people like to refer to it that way and scare people with
those naughty words. I just want to say that I hope that your
secretaryship is marked by our finally achieving that long-
sought goal of providing health access and affordable health
care to every single American.
I know this hearing is supposed to be largely about your
budget, but that is the great issue that hangs over all of our
deliberations on this subcommittee this year. I for one hope
that, as the administration puts together its plans and
establishes its negotiating position, you along with the
President will fight just as hard as he can to see to it that
among the options available to American citizens will be a
public plan.
I find it ironic that some of the people in this society,
especially in the insurance industry, talk so vociferously
about the need for consumer choice, I find it interesting that
many of those same people would deny consumers the choice of
having a government plan. I fully recognize that we are not
going to have anything like the Canadian single-payer plan.
This is a different country than Canada. And I recognize that,
in the end, we will be building primarily on a private
insurance system. But I would certainly expect that we would
have as an option a government plan for those who choose to
have it and not imposed on anybody. I would hope that the
administration would hang tough on that issue.
I know that I am told that the administration is probably
going to be sending down to us additional requests for funding
for pandemic flu, and simply ask you to convey to the White
House that, since we are trying to finish the supplemental
conference this week, they do so immediately so that we can
give it full consideration in the conference.
In my view, President Bush was correct to ask for full
funding for that program more than 5 years ago. This committee,
for a variety of reasons, didn't quite measure up to that. I
think we have got to get on with that business. And so I hope
that the administration will send down to us, as quickly as
possible, whatever their estimates are of what the true need
would be.
I also have some concerns I would like to express to you
with respect to certain aspects of your budget, especially
LIHEAP, and what I regard to be a peculiar request that they
had within NIH which I will save that for the question period.
Mr. Tiahrt.
Mr. Tiahrt. Thank you, Mr. Chairman.
And as a fellow Kansan, I want to provide a warm welcome
for Secretary Sebelius. Congratulations on your confirmation. I
know that after getting back to Washington and seeing the
traffic, you have the same thought that I have: We are not in
Kansas anymore.
As Secretary of Health and Human Services, you have the
responsibility to ensure our Nation's health care and social
services remain excellent and indeed improve. But like a
physician, your philosophy should be, first, do no harm. This
often is hard for the government; for meddling in access and
choice, that government does in fact do harm.
I am interested in hearing how you will balance the desire
to improve access to health care and human services while not
interfering in the quality of the systems themselves. One of
the biggest concerns with government interference in a health
care delivery system that I have is that, and I am sure health
care reform will be a large part of our discussion today, is
that we will limit the innovation to choice and access to this
process that we are going through to try to involve more
government in the process.
The three areas of concern that I have with the
administration's proposals are the utilization of comparative
effectiveness to ration health care; the elimination of the
conscience protection; and the overall concept of moving people
from the private health insurance to public health insurance. I
believe these three policies will negatively impact the quality
in America's access to health care.
First, regarding comparative effectiveness, in the stimulus
bill we included money that not only was for comparative
effectiveness but also language directing your Department to
use this research to make decisions about what treatments the
government will and won't approve. The government will fund
research to decide which medicine or medical treatment works
best for most people. Then and only then will they pay for that
one option.
In other words, ``comparative effectiveness'' is just
another way to say rationed health care. Who is going to be
affected by this policy? Unfortunately, I think it is those who
can least afford to lose will be the ones that experience the
loss.
A fellow Kansan, Jennie Jobe from Johnson County, was in my
office earlier this spring. She has an immunosuppressant
disease. And under private insurance, she had medication that
would allow her to fight off the common cold and the flu.
When she visited my office, she was suffering from the flu
and was afraid to shake hands. She had left the life where she
was completely able to function; she could play with her
grandchildren, she could shop, she could be productive.
Unfortunately when she switched to Medicare, the government
would not fund her therapy or her medication, so she was forced
to take a new medication in which provided her with headaches
and backaches, and it did not protect her from diseases, such
as a common cold.
When she came to my office, she was considering wearing a
mask and was very worried about the H1N1 virus. And it was all
because of the interference in the decision that was between
her physician and herself.
Personalized medicine is a new frontier, and developing
applications to meet these medical needs of individuals as
individuals, as you know our own University of Kansas is
developing the technologies that can not only detect and
analyze an individual's unique physiological response to a
disease, such as cancer, but also tailor the optimum treatment
for that person. The outgrowth of the genomics research,
personalized medicine has already seen success and is realized
at the direction in which medicine should be moving.
In early February, the FDA announced that the creation of a
new position to focus on ushering in new personalized medical
methods came about. On one hand, the government promotes this
personalized medical research, and on the other hand, it is
stymieing the progress through comparative effectiveness
policy. Comparative effectiveness will directly affect a
doctor's ability to make the best decision for his patients.
The Federal Government is the largest customer in the
health care industry. Once it no longer pays for certain
medicines or treatments, it becomes financially unsound for
manufacturers to be able to recoup their costs from research
and development and thus limit their development of new
products. Similarly, innovative research on gene therapy and
other personalized medicine options will be threatened.
Second, I believe that the removal of the conscience
protection will threaten our Nation's health care access. As
Americans we believe that no one should be forced to act in a
way that violates his or her morals or religious beliefs. There
are many excellent health care professionals and health care
facilities that do not believe abortion is a right or is right
and do not provide that procedure. Now the administration wants
to remove their right to refuse and provide a service that
violates their moral principles and/or religion.
Besides the civil rights aspect of this policy, there will
be a severe impact on access to health care. Catholic
hospitals, clinics, and medical professionals are the bedrock
of our health care delivery system in most parts of the Nation.
In Kansas, it is 40 percent of our hospitals. As not-for-profit
hospitals, they take care of all who come through their doors.
They provide excellent care.
But if they are forced to close their doors or stop
practicing, many Americans in Kansas will be left without a
place for medical treatment. I am interested in hearing how the
administration plans to ensure that our health care system
doesn't come to a grinding halt if they stop reimbursing
medical centers for freedom of choice.
Finally, in this area in which I know you are intimately
familiar as former insurance commissioner of the State of
Kansas, I would like to hear about your rationale for moving
people from private health insurance to the public system. Not
only will this exponentially increase the cost to the taxpayer,
but it will also further rationed health care. The
administration has expressed a desire for a public insurance
plan that will directly compete with private health insurance
plans.
Employers will see this as a cost avoidance and move their
employees and their cost from their own pocketbook and bank
account to the taxpayers. We have seen this already in SCHIP.
How will we pay for this as a Nation? Have you accounted
for the vast enrollment beyond just today's uninsured?
Further, current public insurance accounts for about 40
percent of the health care coverage, while private insurance
covers about 60 percent of it. We all know that the
reimbursement rates are much lower than the actual cost when it
comes to the public portion. In Kansas, they are experiencing
from 25 percent to 70 percent below cost on reimbursement
rates. And it is not one entity alone; it is hospitals, clinics
and physicians.
They try to make ends meet by shifting costs from the
private insurance payments to cover the shortfalls in the
public funding insurance. Today in Kansas, one-third of the
physicians will not take any new Medicare or Medicaid patients
because of this. If HHS cannot find a way to meet the seniors'
health care costs, then how will they be able to pay for the
entire populace under government-run health care?
The only way this would be feasible would be a rationed
health care system similar to what we find in other countries,
like Canada, the United Kingdom, Norway, anywhere else on the
face of the earth that has a similar program. And I believe
this is completely unacceptable.
More importantly, I am concerned that it will be the
downfall of the American health care quality and indeed in the
world as we know it as a standard bearer in health care.
Secretary Sebelius, it is good to have you here today. I
look forward to working with you to ensure that every American
has the ability to pursue his or her dream, including access to
the best health care and wellness programs in the world.
Thank you, Mr. Chairman.
Mr. Obey. Mr. Lewis.
Mr. Lewis. Mr. Chairman, thank you very much. I have no
formal statement. I will wait for the Secretary's statement and
hope I will have a chance to ask some questions.
Mr. Obey. Okay. Madam Secretary, please proceed.
Secretary's Statement
Secretary Sebelius. Thank you, Mr. Chairman.
It is good to be with the committee today, and I appreciate
the greetings from my fellow Kansan and new ranking member of
the subcommittee, Representative Tiahrt.
And it is nice to have Mr. Lewis also here today.
I appreciate the opportunity to come and discuss the
President's 2010 budget for the Department of Health and Human
Services. And this does mark my first appearance before this
committee as Secretary. And I want to begin by thanking members
of this committee for your hard work and your leadership. I
know we do face tremendous challenges in our Nation today, and
I hope we can work together to tackle those challenges.
One task we need to complete together is health reform. And
as you consider the budget before you, you and your colleagues
are working on a historic effort to reform our health care
system. Like you, I know America simply cannot afford the
status quo when it comes to health care. We have all heard from
people throughout this country who don't know what they will do
if they or their children fall ill. Too many families in
America are one illness or accident away from financial ruin.
Businesses are suffering as well. Yesterday's bankruptcy of
General Motors reminded us that the cost of health care makes
it more difficult for American businesses to compete and
succeed with their global competitors.
Today a report was released by the President's Council of
Economic Advisors. It outlines how health care reform can help
strengthen our economy and shows us the high cost of doing more
of the same. The report found that if we continue on the path
we are on today, by the year 2040, 72,000,000 Americans will be
uninsured, and health care costs will account for over 34
percent of our gross domestic product. Without reform and
action now, the Federal deficit will continue to rise, and
Americans who receive insurance from their employers will see a
larger portion of their salary go to health benefits instead of
their take-home pay.
This is a problem we can avoid if we act now. The Economic
Advisors' report found that real reform slows the growth rate
of health care costs by about 1.5 percent, would help cut the
Federal deficit, boost our economy, save jobs, and put more
money in the pockets of American families. For a typical family
of four, real income would be up about $2,600 by 2020 and
$10,000 more in 2030, but only if we make health reform a
reality.
The message is clear: health reform can give us a stronger
economy and better health care system and boost families'
bottom line. But if we do more of the same, we all will pay a
heavy price. We need reform that protects what works in health
care and fixes what is broken. The budget we are considering
today invests in key priority areas and puts us on the path to
health reform. It builds on the investments already made in the
21st century health system that you all made in the American
Recovery and Reinvestment Act. It sends a clear message that we
can't afford to wait any longer if we want to get health care
costs under control and improve our fiscal outlook.
Fraud costs our Nation billions of dollars every year, and
the budget proposes that we further crack down on individuals
who cheat the system. The Attorney General and I recently
announced an interagency effort to fight and prevent Medicare
fraud through improved data sharing, joint strike forces in key
areas of the country, and increased operations. This budget
includes increased funding to help HHS achieve our part of the
bargain.
The budget also helps move us toward a central goal of
health reform, improving, as Congressman Tiahrt has already
mentioned, the quality of care. Now, thanks to Chairman Obey's
leadership, the Recovery Act has already included critical new
resources to fight health-care-associated infections, as well
as new support for prevention and wellness programs that can
keep Americans out of the hospital in the first place.
The 2010 budget builds on these investments. The budget
includes critical support for patient-centered research that
will give doctors and patients access to better information and
treatments, as well as quality incentive payments to hospitals
and physician groups who have better rates of readmission. It
invests $354,000,000 to combat health disparities, improving
the health of racial and ethnic minorities in low-income and
disadvantaged populations.
And the budget recognizes that if we want to ensure that
millions of Americans who lack insurance get quality affordable
care, we need to increase the number of health providers in
this country. We are responding to the challenge by including
over $1,000,000,000 within the Health Resources and Services
Administration to support a wide range of programs to
strengthen our Nation's health care workforce.
The funding enhances the capacity of nursing schools;
increases access to oral health care; targets minority and low-
income students; and places an increased emphasis on ensuring
that America's senior population gets the care and treatment it
needs.
Finally, the 2010 budget will support our Department as we
work to protect health and safety of our citizens. As the
recent outbreak of the new H1N1 flu virus reminded us, HHS has
a significant and critical role to play in preparing for and
responding to the outbreaks that threaten the health of
American people. The previous investments made in pandemic
planning and preparation by this committee and this Congress
allowed our Department to respond quickly and efficiently to
the H1N1 virus when it first presented itself and to get
Americans the information and resources they needed early in
the outbreak.
But we still don't know what is coming later this fall and
winter or what exactly will happen this summer in the southern
hemisphere as the H1N1 virus mixes with seasonal flu virus.
Putting safety of the American people first, this
administration's supplemental request will help support the
Federal response to the recent outbreak of the H1N1 flu.
These funds, in addition to the funds requested in the 2010
budget, will allow HHS to continue to respond to the current
outbreak and remain prepared to protect the American people.
Mr. Chairman, President Obama has committed to creating a
safer, healthier and more prosperous America, and this budget
will help our Department achieve those goals. It invests in
reform; will improve quality of care; and continues to provide
essential services that so many families depend on.
I look forward to discussing the budget with you and your
committee today, and I am happy to take your questions.
[The information follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
HEALTH CARE REFORM AND HHS BUDGET PROPOSALS
Mr. Obey. Thank you very much.
Just a couple of things. First of all, with respect to
health care reform, I do hope that as the process moves along,
we will not give short shrift to long-term care. I think that
has to be a key part of whatever we do.
Secondly, without belaboring it, I do take issue with the
administration's request for low-income heating assistance. I
understand that the amount that is being requested by the
administration is significant in historical terms, but it still
represents a reduction below last year, and I would think that
that ought to be corrected.
Let me simply express one concern about your budget for
NIH. I have been on this committee since 1974, and we have
steadfastly, regardless of which party controlled the White
House or the Congress, insisted that allocations to research on
diseases be handled by scientists rather than politicians. And
so we have always resisted efforts to direct a specific amount
of funding at a specific disease.
As you know, and I understand this happened before you were
appointed, that in the administration's initial request, they
have crossed that line, and they have moved to request a
specific amount of funding for cancer and autism to the
exclusion of almost every other disease.
I don't think there is anybody on this panel who is in love
with cancer or autism. I think all of us have a long record,
regardless of party, in trying to combat both.
But I do think that it is important that we recognize that,
once we start politically determining funding levels for one
disease versus another, then the door opens and every group in
society is going to be expecting to be in the front car on the
train. Nobody is going to want to be in the caboose. The result
will be political chaos in an area that ought to be determined
by science.
So this committee will not follow the lead of the
administration on that. I would urge that you talk to whoever
made those decisions and suggest that there is a better way to
skin a cat than that one.
The only other thing I would say, and then I would invite
your comments if you want, on NIH, I would again ask that the
administration as quickly as possible send us your full request
for pandemic flu, because as you know, we had money in the
supplemental that was ridiculed by some of our friends in the
Senate. We have now again put money in--I mean, we put it in
the stimulus initially.
We have now again put a significantly amount of money in
the supplemental. But it is apparent I think to all of us that
even that amount is not enough. So whatever the amount is the
administration is going to request, I would hope that they
would do it pronto.
I simply invite your comments before I pass you on to the
next questioner.
Secretary Sebelius. Well, Mr. Chairman, I will certainly
share your interest in avoiding disease-specific funding in the
future with the administration.
I do know that the President personally feels very strongly
about the opportunity to cure cancer in his lifetime and has
talked about that for years based in large part on his personal
experience. And I think that is a funding initiative that is
reflected in this budget priority.
Having said that, they are also, both in the Recovery Act
and again in the 2010 budget, as a significant investment in
research. And the President also fully supports letting science
guide the research. So I think that is a balancing act.
And I will share your concerns with him.
It is my understanding that the budget resolution, unlike
the initial budget proposal, has retooled the LIHEAP funding in
a way that I think is more suitable in terms of where you feel
it is appropriate to go. I think the goal initially was to
provide a little sort of truth in funding by putting the
trigger in, in case the oil prices were as high as they had
been in previous years.
But I understand your commitment to the program and assure
you that we share that commitment. It is an essential program
for really what are life-saving services for seniors around the
country.
And finally, in terms of long-term care, there certainly is
already an investment and interest in rebalancing a lot of our
long-term care issues, funding more of a continuity-of-care
system, and funding that part of the workforce. This speaks to
the fact that for many Americans, care in their home, care with
some assistance, before they would reach a nursing home, is
much preferable and often provides a much higher quality of
care.
So there are some underpinnings that are already in the
budget, but I think it is very appropriate in the discussion of
health reform overall that we address that issue, because right
now, Medicare does not fund long-term care unless you are
impoverished, and that has become somewhat of an industry to
try and see that families can save some assets as one or other
member of the couple faces that situation. So I think that has
to be part of our discussion going forward. And I look forward
to working with you and others on that issue.
Mr. Obey. Thank you.
I would simply say, with respect to NIH, I think every
member of this committee shares the President's concern about
cancer and autism, but there are also legitimate and equally
important concerns about Parkinson's, about Lou Gehrig's
disease and diabetes, et cetera, you name it. And I think
virtually all of us are more comfortable with the final
decisions being made on the basis of what peer-reviewed process
leads us to the best scientific judgments as opposed to doing a
political balancing act.
Mr. Tiahrt.
COMPARATIVE EFFECTIVENESS RESEARCH
Mr. Tiahrt. Thank you, Mr. Chairman.
I want to go back to the first one on comparative
effectiveness. There was $400,000,000 that the stimulus bill
passed on to your agency, and it is to determine the optimum
procedure or a pharmaceutical for a given symptom.
As we experienced with Jennie Jobe when she came to my
office, she lost access to the best solution for her symptoms
because of Medicare.
How will you apply comparative effectiveness? Will you
allow it to be used like it was for Jennie Jobe as rationed
health care, or will you use it as an advisory tool for
physicians in clinics and hospitals, so they can make the best
decision how to apply the information they have?
Secretary Sebelius. Well, Congressman, let me start by
saying, in my service as Kansas Insurance Commissioner for 8
years, I spent a lot of time and energy fighting the rationing
of health care, which I saw each and every day, being conducted
by private insurers who were making treatment choices and
overruling doctors' medical decisions about drug applications
and medical procedures.
So I share your goal that in transforming the health
system, we not get to a system of rationed care; that medical
protectives should make medical decisions--not government
bureaucrats, not insurance companies, not others.
As you know, the language around comparative effectiveness
research prohibits Medicare from using that research for cost-
based decisions, for spending decisions. So it is established
as a methodology to do exactly what you have just described: to
identify not only best practices and effective outcomes, but to
increase transparency, inform consumers and providers, and move
us in a direction where we are using more cost-effective
treatments, and also higher quality treatments which are in
place in some parts of the country but too often not in place.
Mr. Tiahrt. Apparently, CMS hadn't gotten the memo about
rationed health care because they did ration Jennie Jobe's
health care.
Let me move on----
Secretary Sebelius. That may have been in a formulary that
was created. I have no idea.
CROWD OUT OF PRIVATE HEALTH INSURANCE
Mr. Tiahrt. It is a danger I think that we are facing in
America today. And we are seeing it play out in not only
Medicare but also Medicaid.
In the public health insurance plan currently today 60
percent of health care is privately funded; 40 percent public
funded. And every hospital clinic and every physician in
America today covers the shortfall of public-funded health care
by cost-shifting. They use the term cost-shifting. They budget
cost-shifting. Because as you move towards public health
insurance, how are you going to pay for it? How are you going
to avoid not having the ability to cost-shift as you shrink
that portion of privately-funded health insurance, because that
is the direction that it is going to go?
And here is how it works. An employer has 10 employees. He
pays $500 a month for each employee to have health care. That
is $60,000 a year. If you give him the alternative to push them
into Medicaid, like we did with SCHIP, he is going to say I
have got a $60,000 break here. So he says to each one of his
employees, you know, like you have here, we are going to change
the benefit package; you are no longer going to get health
care, but you do have access to it through Medicaid. And he
saves $60,000 a year, and it comes to the taxpayers to pick up
that cost.
So how are you going to pay for the public health insurance
program that your Department is moving forward and the
administration is moving forward?
Secretary Sebelius. Well, Congressman, I think that the
President starts with a principle that he does not support
dismantling the system that we have for employer-based health
coverage. He recognizes that 180-plus million Americans have
coverage they like, have coverage that they want to keep, have
a doctor they go to.
Mr. Tiahrt. It is not a point about them keeping the
coverage. Excuse me for interrupting, because I am on limited
time. It is not like the Governor's Office where you have
control of all your time.
Today it is going to be an economic advantage for the
employer. The individual won't have a choice. It will be the
employer that makes that decision based on pushing cost to us
taxpayers, which will be a cost advantage to him.
Secretary Sebelius. Well, I would suggest the biggest cost
shift that is going on right now is the uninsured Americans who
come through the doors of that hospital in Wichita and in
Topeka and in Kansas City every day, and those costs are
shifted directly onto private employers who are desperately
trying to keep their employer coverage.
The system of providing a payment for every American, of
having preventive care, of driving wellness care, reduces the
kind of cost shift that we have right now, which falls most
often on small business owners and small coverage. So as the
health plan is being debated and constructed in Congress, I
think that having a fair payment system, having shared
responsibility and making sure that all Americans have access
to more affordable and more effective health care treatment at
the front end prevents the kind of cost-shifting that you have
just described.
SINGLE-PAYER SYSTEM
Mr. Tiahrt. Health care reform does need to occur. I think
we should have a good open debate about whether we use a
different alternative rather than just a single-payer system
that we are moving towards now. And I am glad that you are open
to that debate, and I look forward--
Secretary Sebelius. I am. Congressman, I can assure you
that I don't support and the President doesn't support a
single-payer system. He wants to build on the system that we
have, recognizing that 180,000,000 Americans have coverage they
like, and they want to keep it. We are trying to determine how
to get more effective and affordable coverage for everyone
else.
Mr. Tiahrt. Thank you, Mr. Chairman.
Mr. Obey. Ms. DeLauro.
Ms. DeLauro. Thank you very much, Mr. Chairman.
And welcome, Madam Secretary. What a delight to have you
here today, knowing of your interest in health care and also
your record as a Governor.
I want to say a particular thank you. We have had a chance
to work together with regard to what was happening in rural
America and your focus in that area, but also in this job as
how in fact, with your leadership and the President's
leadership, we will be able to provide affordable health care
for every American. It has been a long time in coming. And we
didn't succeed in 1993, and the problems have only gotten
worst. We cannot fail this time around. And I believe the
President believes that, as do you.
I want to first associate myself with the comment on health
care that the chairman pointed out. I am a very strong
proponent of a public plan as part of the options that we
provide to people today, that it helps us to level the playing
field, and it does provide real choice there.
I would also would remark on the issue of this committee,
and on a bipartisan basis, I think what we have tried to do is
to not pick and choose the various diseases or illnesses that
are focused at the NIH and our other research institutes so
that, while, and I, too, have a personal interest in cancer as
a survivor, but the, if you will, earmarking of autism and of
cancer, I think we are best if we are not picking and choosing.
EARLY CHILDHOOD AND HEALTH CARE
I am going to go to another question, and hopefully in a
second round I will come back to health care. But I wanted to
just briefly talk about early childhood and Head Start if I
might. And the recovery program did provide funding for Head
Start as part of a safety net, but the dollars, as you know,
don't increase the base funding for the program. The Recovery
Act also provided resources for child care and development
block grant, but again it isn't a part of, really, the 2010
budget which only included a slight increase for the block
grant program. And what I wanted to do is to check in with you
about your plans for working to ensure that the increased
Recovery Act funding is sustained in 2011 and beyond with
regard to early childhood and health care and how in fact you
plan to work with the Secretary of Education, Secretary Duncan,
to look at the coordination of services for children who are
under 5.
Secretary Sebelius. Well, thank you, Congresswoman.
As you just said, the 2010 budget does include an increase
in funding for Head Start and early Head Start that would start
with a platform that was put in place by the enormous
investment of the Recovery Act money. And I think that is so
essential. I have had the opportunity to do a lot of work in
early childhood education, and I take very seriously the notion
that this is probably the best single investment we could make
in America. The research on brain development is pretty clear
that between birth and 3-years-old, particularly, is an
enormous growth period.
Secretary Duncan and I have already had several preliminary
conversations. In fact, I had the first one, when I was still
governor of Kansas and he was already the Secretary, about how
the work we were doing in Kansas could be expanded with some
early education money. And I have circled back around now as
the new Secretary to talk about ways that we can have a very
collaborative and coordinated strategy.
I think it is important to have all the early childhood
providers at the table to have a mutual goal about where this
money is best directed, based on science- and evidence-based
research, and also to recognize that all children don't thrive
in identical programs, that we need a variety of programs for
parents and children to succeed. So I can assure you those
conversations are very much under way, and it is a passion that
both of us share.
Ms. DeLauro. The $300,000,000 Early Learning Challenge
Grants, do you have any thought as to how that is going to be
implemented with regard to States and how we are going to look
at that?
Secretary Sebelius. Again, those conversations are just
under way. But I think that what is important is to set up some
kind of a platform for a program that is based on what we know
works in the long run, what gets children ready to go to
school.
We did an alarming study in Kansas a couple of years ago
conducted by the Board of Education that found that about 50
percent of the 5-year-olds who hit kindergarten were not ready
for kindergarten for a variety of reasons. And so early
childhood education needs to target school readiness and close
that learning gap so kids are ready to learn when they hit
kindergarten.
Ms. DeLauro. Thank you.
Thank you, Mr. Chairman.
Mr. Obey. Mr. Lewis.
Mr. Lewis. Thank you very much, Mr. Chairman.
Once again, welcome, Madam Secretary. It is a pleasure to
be with you.
Secretary Sebelius. Thank you.
HEALTHCARE REFORM, H1N1 FLU FUNDING AND PROJECT BIOSHIELD
Mr. Lewis. The last time we had a mutual review of the
Nation's health care system and raised questions and discussed
what the Federal Government might be doing about it was when
Secretary of State Hillary Clinton was then associated with the
President of the United States William Clinton, and he formed a
commission that she headed. And they spent considerable time
and energy reviewing where we should go with our health care
system.
Once the product was developed itself I think many a
message was sent to the Congress that we would be well served
by reflecting upon, or that package hung out there long enough
that essentially the people got a chance to understand what was
in it, and they didn't want it very much. And they sent
messages back to us that were very clear and rather direct.
They said first that which the chairman suggested, and I
believe your statement suggested, that people want first to be
able to keep what they have. And then above and beyond that
they want to ensure that they maintain choice as we go forward
with such a package.
I do not know what a government single-payer system might
lead us to. But a lot could be learned by also not just looking
at the Hillary Clinton Commission, but some of that which John
Maynard Keynes may have taught us about what socialized
processes deliver in the final analysis. All of that will be a
part of the discussion that is ahead of us. It will be a
healthy one and an important one. The Chairman and I have spent
some energy attempting to figure out what we do with a thing
called pandemic flu.
I want to commend the Department for taking on H1N1 virus
seriously and going forward with a program that will attempt to
make sure that we are ready and that we benefit from that which
we have learned so far as a result of work by people like Julie
Gerberding and the like. I note that within your budget there
is a request that includes $354,000,000 for public health and
social service emergency funds.
At the same time, I am concerned that there are plans to
move bioshield money for flu vaccine production. Within that
mix, it is awfully important that we make sure we are not
stealing from Peter to pay Paul, that we have enough money to
ensure that we are protecting the public and our country from
difficulties with bioshield chemical, biological, radiological
problems, et cetera. Could you tell me what your thinking is
presently regarding that funding and if you agree that there
are conflicts that could lead to funding difficulty?
Secretary Sebelius. Well, Congressman, I don't think that
there is any question that the investment made over the past 5
years by this Congress and the previous administration in
preparation and planning and beginning to work on the new
vaccines that potentially are needed for a variety of deadly
diseases have been critically important. And I know this
committee and Chairman Obey and others have been in a real
leadership role on pushing that ahead. I think that as a
governor I was able to see some of the results of that because
we were able to do planning and put a pandemic plan together,
do cross-State preparation, involve private industry, and do a
whole series of initiatives to prepare for an outbreak, which
would not have been possible with only State funds.
So I have seen it both at the Federal level, but also
experienced what those investments have done. I know that
currently we are in the process of evaluating steps forward
with H1N1, and at the same time recognizing that we need to
keep the planning stages in place with BioShield for whatever
eventuality might hit next. So I think that the budget and the
administration's request for supplemental funding to deal
specifically with H1N1 reflects a notion that safety and
security are first. We know what is facing us right now with a
whole series of uncertainties with H1N1. We know we have a new
virus, and we know we have a need to take a look at the
potential vaccine program. But we also know that there are a
series of other outbreak potentials and terrorist acts that
still are looming and we need to do both simultaneously. That
is what is reflected in the budget before you and in the
supplemental request.
NIH FUNDING
Mr. Lewis. Mr. Chairman, could I just proceed with one more
question?
Mr. Obey. Sure.
Mr. Lewis. Thank you, Mr. Chairman.
I can't help but be concerned about the fact that we have
within the stimulus package increased NIH funding
significantly, like a $10,000,000,000 adjustment in that
baseline. As we go forward, I know that your Department is
making a request, it is a pretty modest request, of 1.3
percent, I believe, in the projected year ahead of us. There is
kind of a cliff out there that involves the $10,000,000,000,
and it is bound to create pressures and a shift in priorities,
et cetera. I would appreciate your letting the committee know
what your thinking is and how you are going to deal with that
very real $10,000,000,000 problem.
Secretary Sebelius. Well, Congressman, I would love to tell
you I know what the request will be in 2011. I am aware that
there is a significant investment in the Recovery Act, which I
think is very appropriate and will pay enormous dividends. And
I can assure you that we are going to begin to work and look
forward to working with this committee and the committees in
the Senate side about the future, about a multi-year planning
strategy. Because I think that everyone is aware that there has
been a significant investment, it is basically out there. But
the worst of all worlds is to, I think, key up a number of new
initiatives and then take a huge step back. So, I do look
forward to your ideas and suggestions and working with you as
we look at the out years.
Mr. Lewis. Thank you, Mr. Chairman.
Mr. Obey. Mr. Jackson.
Mr. Jackson. Thank you, Mr. Chairman. Let me first begin by
welcoming the Secretary to our subcommittee and thanking her
for her testimony.
I also want to associate myself with Chairman Obey and
other members who have spoken on the question of specific
earmarks for health-related diseases in this bill. Every member
of this subcommittee has a personal story to tell, every member
of the subcommittee has a case to be made for their
constituents that drove us to seek an appointment to the
subcommittee in the first place from cancer to mental health to
meditation and other forms of health related practices that
could improve the Nation's health. And there is a constant
battle on this committee for the years that I have been on it
to try and find the appropriate necessary resources to address
each of our individual and collective concerns.
HEALTH DISPARITIES
One of my central projects since I have been on the
subcommittee has been addressing issues of health disparities.
When I first got appointed to the subcommittee, then-Chairman
Porter of the subcommittee, while I was trying to advance what
I thought would close profound gaps that exist in our society
insisted on good science.
And he said, Congressman, as much as I want to be
supportive it needs to be driven by good science. So I put
language in an appropriations bill many years ago to address
ethnic and racial health disparities. And the language charged
the top scientists, doctors, and Nobel Laureates around the
country at the Institutes of Medicine to come up with an
approach, a scientific approach that would justify spending on
this committee for addressing some of the profound gaps that
exist in treatment. The scientists named the report, ``Unequal
Treatment.'' And for as long as I have been on the committee
since the report was released, this committee has basically
essentially attempted to follow the path, the roadmap laid out
by these scientists in terms of the appropriations requests
that we make to close these gaps.
Madam Secretary, as you know, many of us on the
subcommittee have made it a point to prioritize reducing health
disparities through a variety of programs at HHS. At the Office
of Minority Health and at the National Center of Minority
Health and Health Disparities, we further focus on reducing
health disparities by supporting many of these programs that
contribute to diversity in the health care workforce. If you
could, and I do understand that the budget lays out
specifically another $354,000,000 for combatting these issues,
could you lay out for us your thoughts, and over time we will
get to even more specific, your thoughts on how the Department
will approach the issues of health disparities?
Thank you, Mr. Chairman.
And thank you, Madam Secretary.
Secretary Sebelius. Well, thank you, Congressman.
And again, thank you for your leadership on that critical
issue of health disparities. I know you have been working on it
for a long time, and the work has paid off to some degree, but
there is a lot more work to be done.
In my first week as Secretary, we released this year's
report on health disparities, which continues to be pretty grim
in terms of the appropriate treatment really by ethnicity is
very disparate around the country. And I think that one effort
that can be enhanced is just the transparency about what is
going on. I don't think there is any question that the debate
that is currently under way about health reform will have an
impact on health disparities, because, unfortunately, what we
know is that, by income and by minority group, the likelihood
of individuals lacking insurance or being under insured is a
predominant case.
And I think having an opportunity for a health home and an
ongoing treatment protocol for every American is a step in the
right direction. Certainly some of the steps to address also
include workforce issues, not one that we necessarily
automatically think as part of health disparities. There is
some investment in the workforce money that looks particularly
for minority students and combines that with underserved areas,
because I think cultural competency is an issue with health
care delivery. And whether or not folks feel comfortable about
seeking out health information and follow it is often due to
whether or not they feel a relationship with the health
provider.
So, in addition to the funding that you have just cited for
specific programs, I think there is another range of
investments on workforce issues, on health reform, that will
also help close the gap of disparities that we continue to see.
MANDATORY INSURANCE
Mr. Jackson. Thank you, Madam Secretary.
Thank you, Mr. Chairman.
Mr. Obey. Mr. Alexander.
Mr. Alexander. Madam Secretary, welcome.
Secretary Sebelius. Thank you.
Mr. Alexander. I have spent a great deal of my time last
week traveling around the State of Louisiana. We had several
health care summits, if you will. We had panelists made up of
physicians, nurses, health care providers, nursing home owners
and so forth.
They are afraid. They are scared about what lies ahead. I
represent the ninth poorest congressional district in the
Nation; I am told one of the unhealthiest in the Nation.
My question is, in Louisiana, we have had a successful
SCHIP program. We call it LaCHIP program in Louisiana. I voted
against the expansion of SCHIP simply because we have not met
all the needs in Louisiana yet, although it has been an
effective program compared to other studies.
I don't know if it is apathy or lack of knowledge about
where people can sign up, but the question is, how now, as we
look at the potential of compulsory insurance, what happens?
How do we make it work? In Louisiana, we still have 100,000
children who are eligible for SCHIP or LaCHIP that are not
signed up. So how do we encourage, how do we engage people to
care and go sign up? And what happens if--do we turn them away
at hospitals, emergency rooms because they don't have insurance
of their own? What happens? How does it work?
Secretary Sebelius. Congressman, that is a great question.
I think that one of my interests in the CHIP program is
certainly taking some of the best practices in enrollment and
trying to assist in spreading those throughout the country,
because there are States that have done pretty creative work
and had great success in enrollment and others that have not.
And I think that one of the key building blocks for health
reform is actually getting folks to enroll and engage in
programs that they are currently eligible for and providing the
coverage that Congress and the administration have seen as a
high priority.
So outreach strategies, assisting with everything from
presumptive enrollment to simplifying enrollment forms are
important. Unfortunately, some States still, rather than
relying on fairly easy technology, are relying on face-to-face
visits, which often are complicated for families that are
working and juggling opportunities. So I think there are a
bunch of strategies that we can engage in in the Departments of
Medicare and Medicaid to make it easier and more seamless for
families to actually enroll their children in programs that
they qualify for.
But I think as we move forward, having discussion and
debate about everything from auto enrollment--which is, I know,
one of the strategies that some Members of Congress are taking
a look at--to presumptive enrollment, to how you make it easier
for people who are eager to find affordable health coverage, to
actually sign up and become engaged, is one of the discussions
that are under way with the committees that are looking at
this. Because the last thing we want is to make affordable
health care have another huge barrier and that be some
enrollment that becomes terribly complicated and sets up its
own restrictions along the way.
We know what has worked in many areas. We know what has
worked for employer care and for other care, and I think we can
take those lessons learned and help spread that information as
we move forward.
Mr. Alexander. Thank you.
Mr. Obey. Ms. Lee.
HEALTH DISPARITIES, SINGLE-PAYER SYSTEM AND SEX EDUCATION
Ms. Lee. Thank you very much, Mr. Chairman.
Hello, Madam Secretary; good to see you. And
congratulations. I look forward to working with you, and I will
just say how delighted I am that you are there in this very,
very critical position.
I want to follow up on Congressman Jesse Jackson's point,
first of all, with regard to health care disparities. As Chair
of the Congressional Black Caucus, along with, of course,
Congressman Mike Honda as Chair of the Asian Pacific American
Caucus and Congresswoman Velazquez who chairs the Hispanic
Caucus, we are working on a health care disparities bill,
closing the disparities, and you know the problems. You have
acknowledged it.
But I am wondering, in this overall health care debate now
that is taking place, we don't hear much in the debate about
this being a critical element of the health care reform
package, whatever package may come out.
So I want to raise that with you, because I have raised
this with the White House several times. And just know that in
this debate, this has got to be front and center for many of
us, because our communities, of course, are the ones who are,
you know, the unfortunate, you know, beneficiaries, the
terrible beneficiaries of these disparities.
Secondly, with regard to single payer, I know the realities
of single payer as it relates to what ultimately will be the
type of health care package that we come up with, but I hope
that single payer is on the table for discussion. I don't think
we need a health care reform debate without looking at all of
the options that exist, and so single payer is an option that
needs to be considered on the table as part of our efforts.
Thirdly, I just want to commend you and the President for
your proposing to end the ineffective and discredited
abstinence-only education programs. For many years now, Senator
Lautenberg and myself have worked on legislation, H.R. 1551,
the Responsible Education About Life Act, that allows for
States--it is very simple--that allows for the States to use
Federal money if they want to teach comprehensive sex
education. It is abstinence and abstinence-plus. So I hope you
will look at that. But I want to commend you and the President
for that.
Finally, let me just say on behalf of Congresswoman Roybal-
Allard, who comes from California--southern California; I am
northern California--she was detained in her district until
this morning. Unfortunately, she couldn't be back in time, but
she wanted you to know she would be submitting questions for
the record and to extend her welcome to you, Madam Secretary.
Secretary Sebelius. Thank you so much. I think that the
health reform debate and discussion is firmly, here at the
Capitol, under way in both the House and the Senate--three
committees in the House and two committees in the Senate--and
lots of you have been intimately involved. So whether it is
single payer or health disparities, that information that you
have the expertise about and the data that you know so well
needs to be part of the discussion as the bills move forward.
And I think that is not only very appropriate, but very
important, that the options be looked at.
As you know, the President laid out some principles that he
believed in with health care moving forward, and he felt very
strongly that we needed to build on the current system and not
dismantle employer-based health coverage. But I know there are
a number of strong advocates for the single-payer system,
particularly here in the House, and I assume that will be part
of the options that you look at as you move along.
Ms. Lee. Thank you. Let me just ask, make a point with
regard to that though.
Yes, we are going to make sure that here in the House that
is laid on the table and that is included as part of the
debate, single payer and health care disparities. But I hope we
hear from the administration the importance of not letting that
slide, because sometimes, you know, we follow in many ways what
the administration is laying out in terms of the general
parameters.
Finally, the HIV-AIDS travel ban. I know HHS sent over a
proposed rule, but it has taken a long time. Do you have an
idea of when we are going to be able to finally lift the ban as
it relates to HIV-positive people coming into the United
States?
Secretary Sebelius. My understanding is that issue is very
much on the radar screen, and it should be soon.
Ms. Lee. Thank you very much, Madam Secretary.
And thank you, Mr. Chairman.
Mr. Obey. Mr. Cole.
NIH FUNDING AND HEALTH CARE REFORM
Mr. Cole. Thank you, Mr. Chairman.
And, Madam Secretary, it is great to have you here. I just
want to quickly associate myself with probably the common
bipartisan sentiment here about directing money towards
specific diseases. If I was drawing on personal examples, I
would talk about Alzheimer's and MS in my family. If I was
looking at my district, I would talk about diabetes for the
Native American population and what that does for the cost. So
once we go down this slope, we would have a lot of arguments
here that would be well-intentioned, but probably not
productive for us; and I don't see how you open the door for
two and not open it up for all.
Let me ask you specifically--I think I know the answer, but
I want to make sure--is the President's position on health care
now that it would be mandatory that everybody participate?
That is somewhat of a shift from the campaign. So has he
made that decision yet?
Secretary Sebelius. He has not, Congressman. As you know,
in the campaign he supported a mandate with regard to parents
with children. He did not support an individual mandate. I
think what he has said pretty consistently, though, is he is
open to engaging in that conversation with Congress. He knows
that a number of Members of Congress are very committed to an
individual mandate, as have been some of the stakeholders at
the table. But at this point, he has not made that part of his
proposal.
Mr. Cole. That, as I am sure you know, is a concern simply
because, while we use a lot of numbers about the uninsured
population, there is always a subset, 25 percent to one-third
or whatever, that really could afford insurance, but choose not
to. So that is going to be a discussion we have.
The second question, because the single payer or government
plan option is a big impediment for a lot of us, and I think it
actually makes a bipartisan compromise much more difficult:
Have you thought about anything modeled after something like
Medicare Part D, which actually has worked pretty well? It came
in at a lot less than estimated in terms of the cost. It has a
high satisfaction rate. The premiums are comparatively low,
lower than we estimated, CBO estimated at the time. It is an
all-private system, but obviously has a government framework to
operate in.
While it was a matter of a great deal of contention when we
dealt with it, it has been interesting to me that almost nobody
has wanted to go back and undo it. It has actually worked
pretty well without a government plan as an option.
Secretary Sebelius. Well, Congressman, I certainly think
that is one of the recent examples of a benefit package that
was put on the table.
I would suggest, though, that it is not accurate to
describe the public option, which would be part of the health
exchange, as a single-payer plan. I don't think that is an
accurate description.
What is envisioned is a health exchange where private plans
side-by-side compete with public plans, and as they do now in
many States in the country in State employee health plans, and
as they do in many States in the country with the children's
insurance program. Absent a public option, in many parts of the
country you would not have choice and you would not have
competition because one private insurer essentially has a
monopoly over the marketplace.
So, again, in my insurance commissioner days, you can
easily design an actuarially level playing field where it
really is a competitive goal. And, frankly, I think that having
a plan that has potentially miserable benefits and low provider
rates is not likely to attract many Americans to choose that
plan if they have a choice of another plan.
The notion of a public plan is to have a health exchange,
where you provide choice and competition--to me, two great
driving features--and give a number of Americans, who right now
don't have a choice and there is nobody to compete with, some
cost competition.
Mr. Cole. I would just suggest a lot of us share Mr.
Tiahrt's concern that that is going to lead us toward a lot of
private employers pulling out and effectively shifting.
I have got very limited time. Let me ask you one last
question here.
You and the chairman in a dialogue, and I think
appropriately so, expressed concerns about long-term care. It
is obviously a huge problem for the country in terms of how you
fund it. There are a lot of folks obviously that clearly start
moving assets early.
Have you thought about or are considering any kind of
expansion of health care savings accounts, again with the idea
that over a lifetime you can build up a certain amount of
capital and use that to defray long-term health care costs? I
am not saying it is a solution for everybody, but the more
people you pull out of the system that way or allow them to
operate that way, the less public cost you might have.
Secretary Sebelius. I have not been engaged in that
particular discussion. I was engaged over a number of years,
and I know it has been a proposal before Congress for years,
that looked at everything from tax credits to incentives for
individuals to do more purchasing of private long-term care
policies. I think the balance always was that a number of the
private long-term care policies did not include very robust
consumer protections, and in fact many of them had cost
escalators that had people paying in for a decade and then the
policy became so expensive that they dropped it and ended up
with nothing.
But we need to look at a variety of strategies, because as
you well know, if you end up meeting the income guidelines,
then you become eligible for long-term care benefits at
basically the State level, and if you don't meet the income
guidelines, Medicare does not provide those benefits. So we
really do have a significant disparity right now.
Mr. Cole. Thank you, Mr. Chairman.
Mr. Obey. Mr. Moran.
INTEGRATION OF SERVICES
Mr. Moran. Thank you, Mr. Chairman.
Welcome aboard, Madam Secretary. I know you are going to
make us all very proud.
The Department of which you are Secretary used to be called
the Department of Health, Education and Welfare. When it was
set up in the early 1950s in the Eisenhower administration, the
idea was to address the whole panoply of needs of the
individual. And they didn't use the term ``holistic'' in those
days, but that is really what they meant.
We haven't achieved that objective. I think in large part
the Congress is as much to fault as anyone, because as the
chairman suggested, we identify particular needs, fund them,
and as a result, we have this vast array of different programs:
different people and programs to deal with education; others
deal with health; others deal with human services; others deal
with nutrition, et cetera, et cetera, all of the various needs
of the individual. The problem is, it is the same individual.
If we really wanted to achieve the most savings, but even
more importantly, perhaps most effectively, address the needs
of that single person, we would start combining and finding
overlapping jurisdictions and find ways that we could better
integrate the services that we are trying to offer. Your budget
alone, even after we take out education, there have got to be
hundreds of programs, and some individuals are eligible for
half of them.
One of the things that has been done around the country,
for example, is to set up school-based health clinics. I know
we had some opposition when I did that as mayor of Alexandria,
Virginia, but once it was set up, we reduced the level of
teenage pregnancy and, thus, abortions. We found any number of
cases of cancer in adolescents who wouldn't have had a checkup
and identified at an early stage, mental health problems, et
cetera; and we achieved the kind of coordination-collaboration
that I think best serves the individual.
Now, I am wondering how you feel about those kinds of
efforts, of achieving more overlapping, more integration of all
those hundreds--myriads of services that you are responsible
for?
Secretary Sebelius. Congressman, you make a great point
that all too often the same family may have people coming at
them from 14 or 15 different angles, and only four or five hit
the mark; and as we just talked about, enrollment strategies
often fail. So I am a huge fan and believer in a systemic and
collaborative approach.
In my brief tenure in this position, I know the President
also shares those concerns and has implored Cabinet members to
come together on strategies, leveraging assets and
opportunities in departments. We have had some robust
conversations already on childhood obesity and strategies of
the Food and Drug Administration.
My first few days in Washington were focused on Cabinet-
wide approaches to address H1N1, and it was a great
illustration of how various members of the Cabinet and various
departments needed to collaborate and cooperate, not just for
that emergency, but on a regular basis.
So I look forward to not only figuring out within our own
agency how to break down some of those silos and put people at
the table on cross-cutting issues, but also to do that with
colleagues in Cabinet agencies. Because often all of us are
approaching the same problem, but through different lenses;
taxpayer dollars will go much further, and programs will be
much more beneficial if we can approach them holistically.
FINANCING HEALTH CARE REFORM
Mr. Moran. Thank you very much, Madam Secretary.
Madam Secretary, the President requested over $600 billion
as sort of a set-aside, seed money for the health reform
proposal, although half of that was dependent upon generating
revenue by reducing the tax deductibility of charitable
contributions. It looks like the Senate has rejected that; so
we are probably at about $300 billion in terms of revenue that
would pay for health insurance overhaul, and yet the cost over
10 years is $1.2 trillion. I should have said the $600 billion
was over a 10-year period. The cost is $1.2 trillion over a 10-
year period, most people assume. So we are really short about
$90 billion a year, $900 billion over the decade.
Are there other ideas that the administration may propose
to Ways and Means and Finance particularly as to means of
financing this gap, or are you anticipating any modification of
the original goals?
Secretary Sebelius. Well, Congressman, that discussion is
very much under way. I would suggest that the President hasn't
retreated from his initial proposals, even on the revenue side,
and I find that as Members engage in the work of trying to
identify where money is available, the proposals are likely to
be back on the table for starters.
Our agency has been asked, as have other agencies, to
identify additional opportunities, and we are in the process of
doing that right now within the Department of Health and Human
Services. I also think that there are opportunities for various
savings that haven't been scored; whether or not they will end
up being scored remains to be seen, but prevention and
wellness, at least in the outyears, may have significant
payoffs.
We are now spending 75 percent of our health costs on
chronic disease, and some efforts to better manage, better
control, and improve outcomes with chronic disease management
have significant payoffs down the road. So we are currently
working on that.
There is also a great belief that the investment in health
technology will pay huge dividends, not just in helping to
drive appropriate protocol, but in lowering medical errors,
again not quite in the system yet.
So there is some work to be done in terms of identifying,
some of those outyear savings that most people agree are very
much there, but just haven't been part of the discussion yet.
Mr. Moran. Thank you, Secretary Sebelius.
Thank you, Mr. Chairman.
Mr. Obey. Mrs. Lowey.
ENDING VIOLENCE AGAINST ABORTION PROVIDERS AND HEALTH CARE REFORM
Mrs. Lowey. Thank you, Mr. Chairman.
I join my colleagues in welcoming you, Madam Secretary.
Madam Secretary, many of us were shocked and saddened by
the horrific murder of Dr. George Tiller over the weekend. For
years, the Bush administration went out of its way to protect
doctors from being forced to provide services they found
objectionable, yet did nothing to shield physicians providing
legal and life-protecting medical care to women from ongoing
harassment, threats and violence. This is unconscionable and
must change. In my judgment, the Federal Government must send a
message that acts of violence against health care providers
will not be tolerated.
I was pleased to learn that Attorney General Holder has
indicated that the U.S. Marshal Service will begin protecting
certain abortion clinics and doctors, and this is a good first
step. Today, the New York Times also called on Attorney General
Holder to revitalize the National Task Force on Violence
against health care providers that was originally established
in the 1990s.
Now, I realize this task force would be under the
jurisdiction of the Department of Justice, not HHS. I want to
know, number one, would you support its revitalization and how
does HHS intend to work with the Department of Justice to
ensure that these acts of violence are eliminated? And do you
agree that this type of violence could discourage medical
schools from teaching doctors how to perform abortions, and how
will HHS work with medical schools and provider organizations
to ensure that this procedure is being taught?
Secretary Sebelius. Well, Congresswoman, I share your
interest in making sure that health services are delivered
within the law and that providers are protected. The Attorney
General was quick to reach out and make it very clear that acts
of violence would not be tolerated, that he would use the
assets of the Justice Department to provide protection. He sent
a very strong message about acts in the future that would be
prosecuted.
I am not familiar with the task force that you have
described, but would look forward to working with you, to take
a look at it. If it is revived, I think the jurisdiction, as
you note, is within the Department of Justice. But certainly
having providers be able to deliver health services to men and
women across this country is essential.
Mrs. Lowey. I thank you.
And following up on another issue, given your experience as
the Kansas State Insurance Commissioner, you understand the
threat to quality and affordable care posed to the insurance
industry when multiple insurance companies merge or have record
profits at the expense of health providers and consumers. In
fact, from 2001 to 2004, health plans in New York State made
more than $5 billion in profits while its hospitals lost $600
million. I think it is interesting that the Westchester County
Association, which is run by many the businesses in Westchester
County, points this out in many of their discussions and
sessions with us.
So, first of all, do you agree that the relationship
between private payers and the financial viability of the
health care system needs to be examined? And if you could share
with us your experiences battling the insurance industry in
Kansas and how that impacted consumers, I would like to know if
there are lessons from this experience that can be applied
across the country and included in health care reform
legislation.
Secretary Sebelius. Well, Congresswoman, I share your
concern about oversight, and my colleagues who are serving as
insurance commissioners across the country have jurisdiction to
review everything from loss ratios to appropriate rate-setting.
Some are aggressive and others, frankly, have very little
choice because often there is a dominant carrier and a single
provider, so the opportunity to have regulatory oversight is
fairly limited.
When I was commissioner in Kansas we had a situation of a
proposed takeover of the Blue Cross-Blue Shield Plan of Kansas
by an out-of-state company, and I ended up ruling against that
takeover ultimately because after reviewing all the testimony,
after having a series of hearings, after having providers and
hospitals come before us, it became clear that the only way to
produce the profit statements to the shareholders, which the
company had promised, was either to reduce benefits or to
reduce payments to providers, all of which would not have been
good for Kansas consumers.
So I do think there is an appropriate oversight role. It is
certainly one that is in the proposal of the public plan. It is
the President's goal and Congressional Members' goal that
either regulatory oversight or competition within a marketplace
work very well, and those things are part of the goal of the
public plan option.
Mr. Obey. Mrs. McCollum.
Mrs. McCollum. Thank you.
Madam Secretary, it is truly a pleasure to have you before
the committee today. The Department of Health and Human
Services has a full plate, and I am very grateful for your
commitment and your team at HHS to work to reform health care
and meet the needs for the services upon which millions of
Americans depend. You have a big job, and I know you will do it
well.
As you know, as Congresswoman Lowey pointed out, on
Saturday an assassination took place in your home State of
Kansas. A physician was murdered. It was an act of terrorism,
and it was in his church. This act of an anti-abortionist
vigilantism inspires fear and terror for not only health care
providers, but for women who need those services. The murdered
doctor had previously been shot, and the clinic in which he had
worked had previously been bombed.
Abortion in this Nation is a legal health care procedure,
and I support a woman's right to make her own health care
choices. The work of the courageous health care providers meet
women's needs daily, and they should do so without fearing loss
of life.
What America witnessed on Sunday was a Taliban-like tactic
to prevent abortions by murdering a doctor. This is terrorism,
and I hope this administration, as you have pointed out, will
continue to extend protection to women's clinics all across
this country. I know that Planned Parenthood in Minnesota--
there was an article in the paper--has been targeted in the
past, and they have received protection.
Thank you so much, and the women in the area that receive
those services also thank you and thank Mr. Holder.
Madam Secretary, I support comprehensive sex education
based on science. Comprehensive family planning and
reproductive health care for all women and counseling to ensure
women of all ages have the best information to make good
choices about when they decide to have their children, that is
how we reduce abortions and that is how we empower individuals
to prevent the need for abortions.
So, I want to thank you so much for your commitment in the
2010 budget to provide women of all ages comprehensive
information and reproductive health services. Thank you, and
you can count on my support to do everything to get that
passed.
HEALTH CARE FOR CHILDREN
But I do have a question. As we take on the challenges of
health reform, I firmly believe that every American has the
right to health care, and this should be especially true for
every single one of our children. As we reform our health care
system, we need to remember that no population stands to gain
more from national health care reform than our children.
Children insured by Medicaid and CHIP are covered under 50
different State programs and the D.C. to account for 51
different programs. A child's access to health care coverage
and health care should not vary by location in this country.
So, the question is, how does the Federal Government ensure
that its most important investment, the investment in the
health of its children, be standardized in terms of uniform
eligibility, national pediatric benefit set, and access to
pediatric specialists for medically necessary care? How can I
work with you to make this a reality, Madam Secretary?
Secretary Sebelius. Well, Congresswoman, I would love to
have a chance to work with you on that critical issue.
As you know, there are some mandated benefits for young
children in the Medicaid packages, which all States must
follow. But beyond that, you have correctly identified that
eligibility rates vary from State to State, particularly for
the CHIP program, and vary regarding the very earliest prenatal
care. So the likelihood of having reduced low-birth-weight
babies and bringing people into the system varies.
This is a huge challenge, and I support--and I know that
the President supports--the notion that the system start with
the focus on children. I think that is why he was so
enthusiastic during the course of the campaign about a mandate
applying to families with children; he felt that we need to
start universal coverage with children.
So I would look forward to working with you to make sure
that all children have access to the benefits you have
described.
Mr. Obey. Mr. Kennedy.
HEALTH CARE REFORM AND OVERSIGHT
Mr. Kennedy. Thank you, Mr. Chairman.
Welcome. Can I ask you, in terms of health insurance
reform, the most basic tenet of health insurance reform is
community rating. That means that insurance companies can no
longer cherry-pick who they cover based upon who is healthy and
who is sick and thereby make their money not by how well they
provide the care and manage the care, but rather how good they
are at choosing this person versus that person to be in their
plan, therefore, excluding the sick people and only covering
the healthy people.
Is the administration going to commit itself to community
rating as an essential part of any health care reform plan?
Secretary Sebelius. I definitely think that the commitment
that the President has made consistently is to eliminate the
preexisting condition opportunities and to move to a system of
affordable coverage for everyone. I haven't seen the specifics
around community rating and how wide the bands would be, but
certainly that is an essential element of the preexisting
condition discussion.
You have accurately described the market as it often
exists, where either a health condition eliminates you entirely
or at least puts you in an unaffordable category. So either
one, I think, would not be part of the health exchange moving
forward.
Mr. Kennedy. That is good to hear.
In terms of the whole issue of insurance oversight, we now
know that insurance companies, it is roughly like 30 cents on
the dollar for administration, versus Medicare and Medicaid,
which is 3 cents on the dollar for administrative oversight.
What is this plan going to do to go into and do a forensic
audit of these insurance companies to ensure that they are not
going to be able to pass along these enormous administrative
costs they have embedded in the current administration of their
plans that they pass on to the consumers?
This is part of something that I think you already know,
being an insurance commissioner, is untenable for us. This is
where our saving is going to be, is going after these 30 cents
on the dollar that never make their way to health care at the
bedside.
Secretary Sebelius. That is one of the essential elements
of having some competition in the new marketplace. A health
insurance exchange would combine private plan options with the
public plan option, and they would compete for benefits and for
costs; and I think that part of the competition is a way to get
to regulatory oversight over the overhead costs.
Thirty cents on the dollar may be high for administrative
costs, but I don't think there is any dispute that the figure
is somewhere in the 15, 20, 25 range, depending on if you are
talking about a large employer plan or a smaller plan. Not only
are those medical dollars not being spent, but the estimate is
that most Americans who have private health insurance currently
are paying another 10 to 15 cents on the dollar for the cost of
those coming through emergency room doors without insurance.
So you get close to 50 cents on the dollar that is not
buying a drop of medicine or a doctor's visit or a wellness
visit or a treatment, and I think that is why we need
competition and why we need choice.
Mr. Kennedy. Would you not say when we have this new plan
that we need to have teeth to enforcing regulatory oversight of
the insurance companies, whatever happens?
I think of what happened recently with AIG, and I think if
we are going to put out to bid billions and billions of
dollars, essentially to manage our dollars in health care for
provision of health benefits, what scares me is I see the
battle on the Hill between Northrop Grumman and Raytheon for a
particular weapons system. I can't imagine the lobbying that is
going to go on up here between health care providers when it
comes to health care contracts.
So, don't you think it is important that we have really
strong oversight at the Department of Justice to make sure that
when it comes to these bidding wars for various health
contracts, that there is government oversight through the
Department of Justice to make sure there are no shenanigans?
Secretary Sebelius. I think the appropriate jurisdiction
for the Department of Justice is probably any antitrust issues
that could come up.
I do think that a regulatory framework makes sense, but I
also believe that competition goes a long way to help regulate
cost, and that if you have a competitive marketplace, you don't
need as heavy a hand in regulatory oversight. For this reason,
I am often an enthusiastic supporter of a public option
standing side-by-side with private plans, and of letting
competition be the determinant of the price and benefit.
Mr. Obey. Mr. Ryan.
UNPLANNED PREGNANCIES
Mr. Ryan. Thank you, Mr. Chairman.
Thank you, Madam Secretary, who is a Buckeye, I must remind
everyone, originally from Ohio, and her father was the Governor
of Ohio at one point in the early 1970s.
One issue that has come up a couple of times is the issue
of unplanned pregnancies and abortions. The President--and I
watched with great interest his speech at Notre Dame, and I
thought he articulated not only a framework for our public
discourse over the next few decades, but also a way of
approaching these controversial issues that we truly want to
find some common ground on. And I know Chairman Obey and
members of this committee have made a large commitment toward
reducing unplanned pregnancies and therefore reducing the need
for abortions and supporting pregnant women.
As you know, Chairman Obey in the past has directed
significant funds towards this purpose, and Congresswoman
DeLauro and I have been working for a number of years to
introduce legislation in the past several Congresses that would
help address this issue.
What is the Department doing, going to do, to try to
implement President Obama 's initiative and partner with
Congresswoman DeLauro and me to reduce the need for abortions?
Secretary Sebelius. Well, Congressman, I think it is an
enormous challenge that we face and one that is something I
have been working on in my home State of Kansas for a number of
years. This issue brings together people who have varying views
on abortion services and provides some common ground: if we can
work to provide a host of services to reduce unintended
pregnancies, we therefore reduce, by anybody's count, the
number of abortions that are performed in this country. I think
this is a goal that all of us could support.
We have a range of services in HHS that work toward that
end. It includes comprehensive sex education, which has already
been discussed. Affordable, available health care is an
important piece of the puzzle. There are adoption incentives
that work along the way. Early childhood education, support for
women, and a range of programs for women and girls that provide
an environment where they have options and choices are all
essential to reducing the situations that produce unintended
pregnancies.
I was alarmed by the recent CDC study that says we have an
increase in teen pregnancies again, after having had a decrease
for the last number of years. That is not good news. We know
that 40 percent of births right now are to single parents. That
is not the hallmark of good news.
So there is a lot of common ground and a lot of work to be
done, and I think that a lot of the assets to do that work are
in the Department of Health and Human Resources. And I look
forward to working with you and Congresswoman DeLauro and
others, because I think this is an issue where some real
focused, collaborative attention can pay huge dividends in the
long run.
STRESS REDUCTION
Mr. Ryan. I appreciate that. And I think Congresswoman
DeLauro and I and other members of the committee would like to
sit down with you and hash this out.
One other topic I would like to touch upon: I feel like
when we have these discussions about health care, there is
always an issue that we never really talk about, and that is
the issue of stress. A lot of us are seeing it now in our
congressional districts because of the economic situation we
are dealing with. And the issue of stress leads to, I think--we
know--increased illness, and these people who are losing their
jobs and losing their health care, it has an effect.
I just want to ask, and we had this conversation a little
bit with NIH, the brain research on being able to regulate
yourself and regulate your emotions and reduce your level of
stress is significant. So when NIH was here, I asked them
specifically about doing more and more research on mindfulness,
and Congressman Jackson brought up meditation and mindfulness-
based stress reduction. They have been studying this for 30
years at the University of Massachusetts and different places
across the country.
I just want to know if you are familiar with this, if it is
a part of your approach moving forward here, the physiology of
stress, the neuroscience behind it. This is a very inexpensive
way to teach kids how to increase their level of attention,
their attention span, their level of focus, how people who are
dealing with the chronic pain you mentioned earlier and how you
want that to be a significant savings, how dealing with chronic
pain can be treated with this method as well.
So I just wanted to see if you are familiar with this and
if there is any approach within the Department to not only
increase the research, but increase the programming and the
education of this.
Secretary Sebelius. I am certainly a bit familiar with it,
but not nearly to the extent that you have just outlined. It is
a prevention strategy that has the potential of paying huge
dividends. I have seen it used as a violence prevention
technique with kids in school, in lessons about various kinds
of control methodologies.
And you see violence levels rise with, as you say, folks
becoming unemployed, and the stress that is related to that. We
will have a new leader in the mental health area soon, and
certainly this issue overlaps with health reform and with work
we are doing with early childhood. I would like an opportunity
to continue this discussion. I am not sure what exactly is
going on now with stress reduction, but I think it is a
wonderful strategy.
Mr. Ryan. I have some information. I would like to get it
to you. I don't want to book up your whole calendar, but I
would like to sit down and talk to you in detail about this as
well.
Mr. Obey. Mr. Honda.
Mr. Ryan. I am done. I guess so.
Secretary Sebelius. But in an unstressful way.
AIDS FUNDING AND MINORITY HEALTH DISPARITIES
Mr. Honda. Thank you, Mr. Chairman.
And welcome, Madam Secretary. Let me again focus back on a
couple of issues that have been mentioned before, and I mention
it because it needs to be mentioned, and when these are not
mentioned it doesn't exist. These are the two things: the
minority AIDS initiative and the issue of health disparities.
On the minority AIDS initiative, I met with the National
Minority AIDS Council a few months ago, and they expressed the
initiative funding has not been reaching the grassroots
organizations, but was being redirected to other priorities
within HHS or being redirected to other priorities, to larger
HIV/AIDS organizations that don't focus on minority communities
and women, but on the white gay population; and that is not the
intention of the MIA.
This year the funding was opened up for competition to for-
profit organizations for the first time, and this put a lot of
pressures on the community organizations and the local
community organizations.
Understanding this, and understanding the possibility of
this pressure on the organizations, what thoughts do you have
about that process? Are you thinking of changing that, or is it
your opinion that it is a fair process, that everybody is on an
even playing ground?
And would you also commit to meet with the National
Minority AIDS Council so they can also express themselves, for
themselves, the way they see the issue? I think that those
issues will come with them, and they will be able to express
that more fully with you. I hope that you would be able to make
some time for them.
The other area is the health disparities, the racial/ethnic
health disparities, the Tri-Caucus. And when we say the Tri-
Caucus, I want to emphasize also that there is a recognition
that there is a stark disparity and that is evident in the
tribal reservations, where very few people take time to visit.
But it is stark, and I think it is time for this country to
take a codel through those tribal areas and look at that and
understand what is going on and what is not happening in those
areas.
Coming back to the other areas of disparities, where we
look at the needs that the communities have, we always talk
about the great expenses that are in the area of health, and a
lot of times it is because we are not paying attention to the
gaps and the disparities in our communities. I think that there
needs to be a conscious discussion and attention paid to the
issue of disparities that exist in our communities for
cultural, social and linguistic reasons; and I think a
blueprint on that needs to be put together so that it will
always be on people's minds as they discuss the critical issues
of health and health care. I was hoping you might have some
thoughts about that.
I know you mentioned disparities toward the end of your
discussion, but it needs to be said up front very clearly, so
that people understand that this is an area that needs to be
paid full attention to as we move forward.
Secretary Sebelius. Well, Congressman, first of all, on the
minority AIDS issue, I would welcome the chance to meet with
the council. In preparation for these budget hearings, this
change in procedure was brought to my attention, and I must
confess I don't know enough about it to tell you if I am going
to change it or not change it. But it certainly is on my radar
screen, and I intend to go back and take a look at how it
operated in the past and why the change was made, and make
inquiries.
I think that not only does competition need to be on a
level playing field, but that we make sure that we get
resources into the hands of folks most likely to reach out to
the population needing to be served. I think that is a very
appropriate question to ask.
Even though it is not in the jurisdiction of this
subcommittee, to your latter point about disparities, the 2010
budget does have a significant request for an increase for
Indian Health Services and one that I would suggest is long
overdue. We have a great new leader who has been confirmed by
the Senate, Yvette Roubideaux, a doctor and Native American who
is coming in to lead the Indian Health Services and who has
worked in this area for a long time. I think there is a
recognition that we haven't lived up to our commitment for
appropriate health services to that community for generations.
In the whole overview of health disparity, the Native American
community has been very much off the radar screen. I think the
President recognized as much in his budget request, which calls
for a 13 percent increase for the Indian Health Service. This
community is one that I will personally commit to paying a lot
of attention to.
As a governor, I worked closely with the tribes in Kansas.
The first day I was on the job, I went to the tribal leaders'
meeting and told them that I want to stay involved and
committed, and I will continue to do that.
Mr. Obey. The gentleman's time has expired.
What I would like to do is to run a 2-minute round so
everybody gets a chance to ask one additional question.
Mr. Tiahrt.
HEALTH CARE REFORM AND PRIVATE INSURANCE OPTIONS
Mr. Tiahrt. Thank you, Mr. Chairman. I will try to confine
all my questions here to 2 minutes.
I think we are on a path to single-payer rationed health
care, starting with competitive effectiveness, the concept of
having a subsidized public insurance company compete with the
private sector. I think we will get further down that path. You
have heard on this committee that many would prefer a single-
payer system.
I would like to see your organization consider some free
market competitive methods of approaching the problem. In many
States, including Kansas, we require everybody who drives to
have car insurance. The result was that we have a fundamental
insurance package for automobiles, for car insurance.
We could do the same thing for a basic health care policy
that included a certain number of visits to physicians,
including hospital days. We can have an annual physical, which
I think would be very good, including counseling for a healthy
lifestyle, which would probably avoid a lot of costs in the
future. We could have an annual dental visit on it, which many
people need as well. We could provide tax incentives for
everybody to purchase a basic health care policy, and if they
couldn't afford it, a voucher--for example, those under the
poverty level--where they could go out and shop for it.
It would have a provision that I think would address the
need that Mr. Kennedy brought up, a very compassionate man, who
knows there are some people who get denied coverage. In the
example of auto insurance, we have a high-risk pool where each
provider takes a turn at drawing a name from a pool which would
cover people who have preexisting conditions.
It is an alternative that would provide competition. It
would be lower cost. And if you look, right now health care is
about 20 percent of our gross domestic product. If we did
privatize or take the privatized portion and move it into the
public sector, it would cost at least $1.5 trillion a year.
That is almost a 50 percent increase in what our current
Federal budget is. I don't think we can afford that in today's
economy. So for us to provide an insurance plan that would be
competitive would be a good alternative.
Would you consider developing a basic health care policy
that could be considered as part of the debate?
Secretary Sebelius. Well, Congressman, those policies exist
across the country, and in most cases they are not attractive
to other employers or employees going to an individual market,
which is really the description that you are giving, is not
what insurance is about. It is about sharing risk.
People right now are interested in getting in a pool where
they are pooling their own health situations with others and
driving the market. This has been suggested, I would say,
strongly, in the last 8 years. It was the administration's
primary suggestion for solving the health crisis--having all
Americans move towards individual coverage. Dismantling the
employer coverage that we currently have is not something that
I support, and I know it is not something that the President
supports.
Mr. Tiahrt. Perhaps you misunderstood me. It is not a pool
of one, it is a pool of 300 million. It would be a policy that
would be applicable to everyone. So I think that is something
that I would like you to consider.
Secretary Sebelius. If you are talking about a health
exchange that you could join as an employer or an individual,
that is exactly what is being contemplated, with a benefit
package that would be affordable.
Mr. Tiahrt. I will be glad to look at it.
Thank you, Mr. Chairman.
Mr. Obey. Ms. DeLauro.
Ms. DeLauro. Thank you, Mr. Chairman.
Madam Secretary, just let me make a comment, and I will get
the piece of legislation to you. I think my colleague Mr.
Kennedy would be interested in this. It is called the Informed
Consumer Choices in Health Care Act. Senator Rockefeller
endorsed it in the Senate, and Congresswoman Schwartz and
myself have introduced it here.
It would provide consumers with a coverage facts label,
similar to the nutrition label, which would streamline--it
would make it consistent as to what was being offered so people
could understand what is being offered.
Secondly, it creates a Federal Office of Health Insurance
Oversight to deal with oversight and regulation. Obviously, the
States have a major portion of that, but at the Federal level
it would be helping to monitor that effort. I would love to get
your thoughts, taking a look at conceptually whether or not
this is something that can fit in with the health care debate.
FOOD SAFETY
Let me move quickly to food safety. I know you have had
just a little bit of time to settle into the Department, and
you do cochair the Food Safety Working Group. I was wondering
what you see as clearly the most important goals and
objectives. How do you believe we ought to measure its success?
A final comment there is, you know where I stand on the
issue of food safety functions and taking them out of the FDA
to an agency that has its own commissioner and its own agency.
Is this an idea you would be open to considering?
Secretary Sebelius. I am enthusiastic about the
collaborative work between the Department of Agriculture and
HHS on food safety, and certainly appreciate your passion and
leadership on this issue over the years.
We have a new commissioner of the Food and Drug
Administration, Peggy Hamburg, who has now been confirmed. The
deputy is in place.
Redoing the inspections and food safety system is
essential. It has got to be a public-private partnership.
Whether or not it is a stand-alone agency or in the Food and
Drug Administration, I think is almost secondary to what the
system needs to examine. I am eager to restore the FDA to its
gold standard, which it certainly is a long way from right now.
Ms. DeLauro. Thank you.
Mr. Obey. Mr. Lewis.
STATE AND COMMUNITY INVOLVEMENT
Mr. Lewis. Thank you, Mr. Chairman.
Madam Secretary, historically our health insurance programs
and systems have been driven by the individual States. New York
State law used to dominate this whole arena. Commissioners
across the States play a significant role. You had that
experience yourself.
You have indicated, by way of your statement for the
record, that you intend to begin by building on the system that
we have. Doing that, do you see the Federal Government's role
being one of cooperatively working with the individual States,
trying to react and support their challenges and their solution
or do you foresee a more centralized Federal Government system?
Secretary Sebelius. I met with my former colleagues the
other day; the insurance commissioners were here dealing with
this very issue and coming to lobby some of you, I am sure.
I am a strong supporter of the consumer protection role
that States play in the health insurance area; I was engaged in
that myself, and I saw firsthand the individuals covered by
ERISA plans who really had nobody to turn to if those benefits
were denied or if the claim wasn't paid or if the company
suddenly ceased offering insurance. So I am a strong believer
that there is an important consumer protection role, and also
an important oversight role the States will continue to play in
the future.
Markets are often regional or local, and I think having
somebody in that role who understands that and not a cookie-
cutter approach that is nationwide makes very good sense.
Nothing I have seen being discussed runs counter to that at
this point.
Mr. Lewis. Thank you.
Mr. Obey. Mr. Jackson.
Mr. Jackson. Thank you, Mr. Chairman.
Madam Secretary, I have been a longstanding supporter of
community health centers because in my district health centers
provide access to affordable, high-quality, culturally
competent care to medically underserved individuals who might
otherwise go without. I know that President Obama is well
acquainted with the central role health centers play in health
care in Illinois and nationwide. Indeed, the President recently
stated, ``Health centers, primary care and prevention are at
the heart of my plan for an affordable, accessible health care
system.''
My first question: Do you agree that we must continue
growth of this important program as we undertake comprehensive
health reform?
Secretary Sebelius. Yes, I do.
HIV/AIDS, HEALTH DISPARITIES
Mr. Jackson. Secondly, the epidemic of HIV and AIDS
continues to rage in the African American community. According
to the CDC, even though blacks account for about 13 percent of
the population, they account for about half, 49 percent, of
people who get HIV and AIDS.
I am pleased to note that while CDC's budget continues to
prioritize prevention, testing and treatment activities among
African Americans, I am concerned that the program entitled
``The Heightened National Response to the HIV-AIDS Crisis in
the African American Community'' has been slow to mobilize to
conduct the HIV and AIDS testing activities called for in the
initiative.
Madam Secretary, can you please review this situation and
see what needs to be done to facilitate this important testing
activity?
Secretary Sebelius. Yes, I will.
Mr. Jackson. Thank you.
Thank you, Mr. Chairman.
Mr. Obey. Mr. Cole.
FINANCING FOR HEALTH CARE REFORM
Mr. Cole. Thank you, Mr. Chairman.
We all agree, whatever our stance is, it is an enormously
expensive undertaking for health care if we have a government
program. It is expensive for families individually. So I have
got two questions.
One, is the administration considering taxing current
health care benefits to pay for the expansion of health care?
And, second, is the administration considering allowing those
who are not in employer-based plans, that are paying for health
care currently, or insurance, with after-tax dollars to do it
with pretax dollars, to have the same deductibility that people
that are covered governmentally or by private companies have?
Secretary Sebelius. Congressman, as you know, during at
least the course of the campaign, the issue of taxing employer-
based health coverage was discussed in a fairly robust fashion.
The President opposed then and continues to oppose taxing
employer-based health benefits, as he feels that it would
dismantle the current system that 180-plus million rely on.
Having said that, he also proposed and continues to support
tax credits, particularly for small employers, but for a
variety of individual employers who are currently struggling in
the marketplace. And he has said he is open to further
discussions about the whole taxing issue.
I think there is no question that looking toward the
future, there are a variety of ideas on the table in both the
House and the Senate. But at this point he feels that providing
a tax to all employer benefits would dismantle the market that
so many rely on.
Mr. Cole. Thank you. Thank you, Mr. Chairman.
Mr. Obey. Ms. Lee.
RECOVERY ACT FUNDING: MINORITY OUTREACH, MENTAL HEALTH SERVICES
Ms. Lee. Thank you very much, Madam Secretary. A couple of
things with regard to the Recovery Act funding. One is as you
know it is very difficult oftentimes for communities of color
to access Federal funds for grants. And so I appreciate the
diligence and the urgency that HHS has placed in putting these
funds forward that we provided in the economic recovery
package. But I wanted to see if you had any specific outreach
efforts for the African American, Latino, Asian-Pacific
American and Native American communities to be able to compete
with these funds, and if so, how you are coordinating that?
And also ensuring that minority serving institutions such
as Hispanic serving institutions and historically black
colleges have the benefit of being able to understand and
compete for these funds so that they can certainly access them.
And then secondly, I wanted to ask you about mental health
services as a part of the economic recovery funding. I know we
provided funding for a variety of health care strategies and
initiatives, but how does mental health fit into that. And
finally, thanks to Congressman Kennedy and others, his father,
Senator Kennedy, we do have mental health parity now as the law
of the land. And so have we considered that in the allocation
of the funding under the Economic Recovery Act?
Secretary Sebelius. In the Recovery Act, there is a new
stream of funding that is targeted for capacity building of
community and not-for-profit organizations that, while not
exclusively targeted to minority groups, certainly would be an
applicable source of funding to build capacity of the
neighborhood resource groups that are often so vital to deliver
services. Back to Congressman Jackson's notion, there is also
an expansion, as you know, of community health centers, and of
the workforce in community health centers, through minority
student loan assistance designed to increase the number of
health providers.
So there are a series of strategies under that umbrella to
target services to appropriate populations. This 2010 budget
request also includes an increase request for mental health
services, particularly for children. It has a grant proposal to
serve 11,000 more children and provide services, to 35,000
additional parents and siblings, something that I know
Congressman Kennedy and others have worked on diligently.
Expanding those health services is an important feature of this
budget request.
Ms. Lee. Thank you.
Mr. Obey. Mr. Kennedy.
EARLY EDUCATION; MENTAL HEALTH SERVICES
Mr. Kennedy. Thank you. Madam Secretary, thank you for
mentioning that. I think if we could elaborate on the expansion
of services for young people mental health needs, could you
explain your work with your counterpart, Arne Duncan, about
early education and how we could better use the monies that are
being appropriated for Head Start early education programs from
his point of view and his Department so that the dollars are
really used where they are needed the most as opposed to across
the board. Because frankly we need to target the dollars,
target them towards children who come from families where there
is domestic violence, where there is depression, where a parent
is in jail, where there is addiction. We know those are the
dollars that are going to go to make the biggest difference as
opposed to trying to blanket the whole country with dollars for
every child. We would love to do that for every child, but
frankly, in the metrics of things, those aren't going to be as
successful as if we really target the dollars to where they
make the most sense.
If you could respond to that as one point. And then the
second point is in terms of the prominence of mental health in
the administration and where it will figure in to health care
reform. Obviously there has been no appointment yet to the
SAMHSA director. But could you comment on the notion of a
medical home as a central part of any health care reform,
meaning coordination of an integration of services, and mental
health being a key part of any medical home that is being
adopted under the President's plan for purposes of
reimbursement and particularly the ASPR program which
reimburses doctors in the white coat community through the ICD
codes for their work doing brief screening intervention and
treatment for mental health services.
Secretary Sebelius. Congressman, I know you have done
extraordinary work in this area, and I would look forward to
learning more about the identification that you have been able
to make of what are the most cost effective strategies and the
best practices, because they exist. But I can tell you that
there is no question, as we look at overall health costs, that
focusing on mental health as a strategy is going to be
extraordinarily effective. Depression is often an underlying
related link to a number of chronic diseases that we just
talked about as being one of the cost drivers and vice versa.
If you suffer from depression, you often are more likely to
have some of the conditions which create chronic disease. So
there is a partnership there that has to be addressed as we
look at ways to reduce not only the 75 percent of health
dollars we are spending on chronic disease, but also to produce
healthier lifestyles in the long run. The earlier
identification of precursors to mental health issues is done in
young children. So having a strong link in the early childhood
Head Start community with those warning signals of violence
potential and high stress households and, as you say, substance
abuse households and focus on those children as an early
prevention strategy also pays huge dividends down the road.
We have had those discussions with potential SAMHSA
directors and are looking for somebody who really understands
that this can't be an isolated strategy, a stand-alone or a
second or third chapter; it has got to be at the forefront of
our dealing with health reform.
Mr. Kennedy. Thank you very much.
Mr. Obey. Ms. McCollum.
OVERSIGHT AND MEDICARE REIMBURSEMENT DISPARITIES
Ms. McCollum. Thank you. And thank you for your comments
about Indian health care services. I was just with Ojibwe, the
band in Leech Lake, Minnesota and Malax, Minnesota. They are
very excited that there was an increase. They are very happy
for the other tribes who have seen their health care facilities
being listed in the upgrades. They are anxiously awaiting their
opportunity as well, so I know that we will be working with you
with that.
And I was with some Pueblos in New Mexico too. In fact, I
will get some information to you. I personally was in a
hospital that I thought should have been shut down. I was very
concerned about the patients who were there, and the patients
who were there were concerned about the type of health care
they were going to get. One Pueblo had great health care, one
moderate and another one was awful. I want to also let you know
I am going to be submitting a question for the record on health
care technology.
I am concerned about some of the contracts, and I know the
chairman was trying to get copies of all the contracts that had
been submitted by the administration for providing many health
care services, but I am very concerned about a health IT
contract that was submitted under a previous administration. I
am very supportive of health care but I don't want the fox
watching the hen house, and that might be happening. But I
would like to just very quickly point out to you that I am very
concerned about low cost high quality states like Minnesota. We
are doing everything the Medicare program could ask to have
done. We are delivering services in a cost effective manner yet
we are being hammered. We are losing physicians because of the
reimbursement formula.
So I applaud you for making high quality health care long-
term sustainability of medical and health care reform a
priority. But I urge you, as we move forward, to bring a
comprehensive health care reform, I urge you, I can't urge you
enough, to carefully craft provisions to avoid having
disproportionate impacts on Medicare beneficiaries like States
like Minnesota that are doing everything that is asked for
them, but at times being paid half, half the amount for States
with doctors and facilities that are delivering abysmal
outcomes compared to what we are doing.
Secretary Sebelius. It probably won't come as a great
surprise to you that I just had this conversation with Senator
Klobuchar an hour or 2 ago before I came over here, so I am
very well aware of that situation. And the last thing we want
to do is discourage high quality lower cost services from being
delivered. In fact, we want to highlight them, not only as best
practices but to drive other systems toward delivering that
same kind of care. So whether it is Mayo or others who are at
the front of the line, I can assure you we are taking a careful
look at how we can make sure that doesn't happen in the future.
Ms. McCollum. Mr. Chairman, I have some bedtime reading for
you on the IT issue.
Mr. Obey. I will think about it. Mr. Honda.
Mr. Honda. Thank you, Mr. Chairman. Quick things. You have
two great experiences in your background; one is being
governor, the other is commissioner of insurance. As us, with
the governor's background in your current position, have you
thought about having your Department do an internal audit in
terms of them asking themselves where are the gaps that we
think are there? And perhaps there might be an exercise that
can be done administratively where they can do the internal
kinds of questioning so that they can perhaps just by
themselves come up with some identifications of gaps in
services and disparities. It can be everything from CDC to
medical school and things like that.
Second, as commissioner of insurance--I know that there is
50 states and territories. I also know that when I ask the
question about antitrust and its role in health costs and other
costs in this country, the issue of reimbursements from the
Federal Government to the cost of medical services and doctors
being able to afford protecting themselves through insurance
premiums. What impact would there be if there were antitrust--
if we brought the insurance companies under the Federal
antitrust laws as the other corporations are.
I could get my answer in writing if you want, but it is
still on my mind, these kinds of things. And I am not an expert
on these areas but it certainly seems like the insurance
companies are players in a lot of these arguments we have about
premiums, rising health costs and things like that.
Secretary Sebelius. Congressman, I am not quite sure what
the system is that you are describing for the future, but I can
tell you that oftentimes there is a prohibition that currently
exists with companies collaborating in terms of price fixing,
having discussions prior to submitting rate proposals on what
prices should be. But there are varying degrees of oversight
that currently take place in terms of rule submissions and loss
ratios. So as we move forward in health insurance and health
reform, one of the issues is, can you deliver an insurance
package to more Americans at a more affordable rate? And again,
I am a believer that not only appropriate oversight is
important, but competition is very important. And I have seen
that work effectively in marketplace strategies over and over,
which, again, is why I think that having some public options
side by side with the private plans is the way to keep a
competitive marketplace and give consumers and employers the
kind of choice they need.
Mr. Honda. Thank you.
Mr. Obey. Mr. Tiahrt, did you have one last question before
we shut it down?
Mr. Tiahrt. No, thank you.
Mr. Obey. Madam Secretary, let me simply add my voice to
the remarks of Congresswoman McCollum on reimbursement rates.
These reimbursement disparities are outrageous in my view. I
just hope that people putting this bill together in the end
will understand that they would make a big mistake if they
would take for granted the support of people from States like
Wisconsin and Minnesota if this outrageous disparity in
reimbursements is not corrected to a significant degree. Our
States feel like we have been taken for suckers for years, and
those outrageous disparities are just going to have to shrink
significantly if we are going to get a product that everybody
can support. With that, I thank you for coming. I am happy to
see you where you are. We look forward to working with you and
will see you again. The committee is adjourned until 2:00
tomorrow afternoon. Thanks.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Wednesday, June 3, 2009.
U.S. DEPARTMENT OF EDUCATION
WITNESS
HON. ARNE DUNCAN, SECRETARY, U.S. DEPARTMENT OF EDUCATION
Chairman's Opening Remarks
Mr. Obey. Good afternoon, Mr. Secretary. I will give you a
minute to get organized.
Well, Mr. Secretary, welcome. This job would be a great job
if we didn't have to vote, but I am told that, within a couple
of minutes, we are going to get some roll calls on the House
floor which will discombobulate this hearing. But we will try
to do the best we can.
Mr. Secretary, I am not quite sure where to start. Let me,
first of all, state that we want to be on the same team. We
want to work with you. We want you and this President to
succeed, and we enjoyed the opportunity to work with you on the
initial stimulus or recovery package, as people are now calling
it. But Will Rogers said once that when two people agree on
everything, one of them is unnecessary. And I find myself in
that position this afternoon, as I indicated to you to some
extent yesterday, and let me paint you a picture of what is
happening in my district.
UNEMPLOYMENT IN THE CHAIRMAN'S DISTRICT
A year ago, Taylor County was riding at 7 percent
unemployment; today, it is 14.5. Rusk County a year ago, 7.3;
today, 17 percent. Polk County, 5.9 percent a year ago; 12.5
today. Oneida, 6.7 a year ago; 12 percent today. Marathon, 4.1
percent a year ago; 9.4 today. Lincoln, 5.3 percent a year ago;
12.6 today. Langlade, 5.8 a year ago; 12.1 today. Iron, 8.7 a
year ago; 14 percent today. Clark, 5.7 a year ago; 11.3 today.
Chippewa, 5 percent a year ago; 11 percent today. Burnett, 7.1
a year ago; 13.2 today.
Now, I cite those numbers to try to make a point, which I
will eventually get to.
RECOVERY ACT FUNDS AND BUDGET STABILIZATION
As you know, we tried to--in the stimulus package, we tried
to take into account that this was happening and that is why we
provided large amounts of money to States to try to stabilize
their budgets. That is why we provided a good deal of
additional funding in direct financing to local school
districts by formula. And if you take a look at what is
happening around the country, according to the Center on Budget
and Policy Priorities, some 47 States are facing fiscal stress.
According to one analysis from the University of Washington,
State education budget shortfalls could result in the loss of
nearly 600,000 jobs in K-12 education alone.
Mr. Secretary, you have established certain principles to
guide the expenditure of Recovery Act funds: one, to preserve
and create jobs; two, to improve student achievement through
innovation and reform. And you have been quoted as saying that
schools face a perfect storm for reform. That may be, but I
think that they also face a devastating storm in terms of just
general economic conditions. I am concerned that there are so
many communities that are so cash strapped that they are using
Recovery Act funds simply to mitigate State and local revenue
shortfalls in order to prevent layoffs; and, for those
districts, all they may be able to do is to pay for existing
teachers, keep the lights on, and pay for other essentials.
TIMING OF PROPOSED INITIATIVES AND ECONOMIC TURMOIL
If the first focus of States and school districts is to
plug these devastating budget gaps and avoid deep layoffs, then
I think it is legitimate to question whether it is realistic to
also expect them to implement dramatic new reforms until the
economic situation stabilizes. I don't want to set them up for
failure in the public's eyes because they can't do two things
at the same time because of the extreme economic collapse that
we have seen in the country, and so I would hope that you would
take that to heart in the way that you administer the funds
under your control.
Secondly, I have been on this committee for almost 40
years, and I think I have got a track record of giving a damn
about what happens to these programs. But I am not so much
interested in programs as I am performance. And I am certainly
supportive of reform, if that process occurs in the context
that makes it possible for people to think about reform.
I voted for No Child Left Behind because I thought the
previous President had a right to have his first domestic
priority supported. Unfortunately, I overestimated his
willingness to live up to the financial commitments attendant
to that deal.
PROPOSED EDUCATION BUDGET INITIATIVES
But I am concerned, frankly, about the direction some of
your budget decisions would take us. You request $800 million
for new early childhood education, $300 million more for new
reading initiatives, next, $100 million to expand the
Innovation Fund and to scale up best practices from $650
million in the Recovery Act to $750 million in your budget. You
propose a large increase for the Teacher Incentive Fund which
supports the design and implementation of performance-based
teaching compensation systems, more than quadrupling from $97
million to $487 million, and to $717 million with Recovery Act
funds, even though the Department has yet to complete any
rigorous evaluation of the effort which began 4 years ago.
ESEA TITLE I DECREASE PROPOSED
I want to support the Administration and its education
priorities but not at the expense of reliable and predictable
Federal support for thousands of school districts across the
country that depend on that funding. And I confess I find
troubling the $1.5 billion, or 10 percent, cut in basic Title I
grants that you provide for in your budget in order to finance
these new initiatives.
In essence, your budget would force school districts to
backfill this deep reduction with Recovery Act funds. It will
put additional strings on Title I by requiring districts to
commit other Recovery Act funds to start new preschool programs
as a condition of receiving Title I early childhood grants, and
I am not at all convinced that that is not unfair and untimely,
given the economic situation.
PROPOSAL TO MAKE PELL GRANTS MANDATORY
I also want to express reservations about your higher
education budget. I am a huge fan of Pell grants. I have been a
champion of Pell grants every year I have been in this
committee. But I confess I am dubious about the wisdom of this
committee, in the midst of trying to convince people that we
are responsible financially and fiscally, I am not convinced
that this is the time to create another, in essence,
entitlement by putting another program on automatic pilot. In
fact, I am concerned that the recommendation that you have with
respect to Pell might in fact have a perverse reverse effect
by, in essence, actually putting a ceiling on the amount of
future increases in the maximum award under Pell.
So, as I say, we are all friends here and we want to work
together, but I have got to be honest and lay out my misgivings
about some of the directions that I see you and the
Administration going in, and I hope that we can work them out.
Mr. Tiahrt.
Mr. Tiahrt. Thank you, Mr. Chairman.
Welcome, Mr. Secretary. Congratulations on your new role
here.
You have a very interesting history. I think you have
accomplished quite a bit in the State of Illinois and in
Chicago, and I think those accomplishments would not be
classified particularly as supporting a Democratic point of
view or a Republican point of view. I think you took a
refreshing approach in a lot of new areas.
I understand you have a background in basketball. Each
year, Congress plays the business community in September and we
are going to try to recruit you for that game.
EDUCATING THE NATION'S WORKFORCE
We hear a lot about a changing economy and changing world
and a need to prepare our children to participate in the 21st
century and in the job market that is going to be coming about
during that time. In the last Administration, we worked a lot
on accountability and how to best ensure that school districts
help every child reach his or her potential. This is still an
issue, and there are many debates surrounding No Child Left
Behind and the emergency alternatives such as charter schools
and the like, and we will probably discuss that later. I look
forward to hearing your views on accountability and how to fix
No Child Left Behind without discarding, quote, principles that
I think we all agree upon.
As for the issue of preparing our workforce and children
for the future, I would argue that the future is here. It is
today. Michael Wesche of Kansas State University has done a lot
of research about today's technology revolution and its impact
on society, the marketplace, and education. He correctly points
out that we need to be adapting faster and more efficiently in
order to keep up.
I do have concerns, however, with his views and others and
the insistence that the education systems of old are outdated
and should be overhauled. Yes, new technologies need to be
incorporated into classrooms from a young age so that children
can learn how to use these tools and be safe while they use
them. And, yes, schools should work to capture the attention of
a child. But these aren't new issues or new views. There have
been age-old education problems from which slide rules have
transformed into calculators and one-room schools into the
separation of grades and ability levels. Our school systems
should be challenged to continually meet those needs and
continually improve.
There is reason to be concerned, however, that we push to
move out of the traditional classroom and permit children to
not pay attention to lessons they do not feel are relevant to
their future careers. Besides basic knowledge of the world
around us, one of the most important aspects of education is
teaching us how to learn and how to analyze new information and
to put it into use, how to focus on issues that might not be to
our liking or in which we may not have a natural aptitude, how
to meet deadlines, how to work with others, how to still learn,
and so on.
Most of what I learned in school was not applicable to my
job as a systems engineer or as a proposal manager and
certainly not as a Member of Congress. But the fundamentals are
age-old and should not be thrown out with the bathwater.
I am interested in hearing your thoughts on this issue and
how we balance the desire for more technology and personal
education and make sure our children are prepared to meet the
timeless challenges of learning in a real word.
EDUCATION, JOB TRAINING AND RETRAINING
Education and retraining are keys to ensuring that American
workers are the most competitive around the world. Modern
economies are driven by knowledge and skills. Just as America's
public education system changed the notion that schooling is
for the upper class, we now need to change the notion that
education ends at 18 or 22. Job retraining and school
enhancement are in addition to schooling. They are part of the
larger continuum, a lifelong pursuit of education.
Most importantly, for the short and long term, we need to
help Americans access not only higher education but also
continuing education. Job training and retraining is necessary
to keep up in today's environment.
I also have a couple of concerns about overall spending and
specifically the impacts that the chairman made about Pell
grants and the mandatory program, rather than discretionary.
But in this changing world we need innovative ideas and should
have a vigorous debate on how to best educate our children.
I look forward to working with you and to ensure that every
child achieves his or her dream.
Thank you, Mr. Chairman.
Mr. Obey. Mr. Secretary, please proceed.
Opening Statement of Secretary Arne Duncan
Secretary Duncan. Thank you so much, Mr. Chairman. I just
appreciate your support and decades of leadership on this issue
and your passion. I look forward to working with you to
dramatically improve the quality of education for children
around the country, and I appreciate the tremendous leadership
you have shown for a long, long time on these issues.
FY 2010 EDUCATION BUDGET PRIORITIES
Thank you for the invitation today to talk about President
Obama's fiscal year 2010 budget request. This budget makes
important choices to continue and expand programs that will
support our children from cradle to career. It provides the
resources necessary to expand access to high-quality early
childhood programs, to ensure that our K-12 schools are
preparing their students for success in college and the
workplace, and to provide college students with the money they
need to pay for college and the assurance that the Federal
Government will be there to help them. Together, all of these
policies will help our children reach the President's goal
that, by 2020, the United States once again will have the
largest proportion of college graduates in the world.
U.S. 1ST IN WORLD IN COLLEGE GRADUATES BY 2020
Secretary Duncan. I just want to stop there for a moment. I
think that is a very ambitious goal. I think it is critical.
About 20 years ago, a generation ago, we led the world in the
number of college graduates. It is not so much that we have
declined; we have flat-lined, and other countries have passed
us by. I think that presents some real challenges for our
country and for our long-term economic vitality.
AMERICAN RECOVERY AND REINVESTMENT ACT
I am extremely grateful for the work you have already done
to help our Nation's schools, and I look forward to working
with all of you in the future. As you know, in the American
Recovery and Reinvestment Act, you provided $100 billion to
schools and to students. The law provides a phenomenal start in
addressing the needs at every point along the cradle-to-career
spectrum. Thanks to your support, we were able to stave off an
education catastrophe and save a generation of children. And we
estimate as many as 375,000 jobs can be saved with the money we
have given out already through the first round of stimulus
funding.
As you know, ARRA had two goals in education: to create and
preserve jobs and to promote school reforms. Even though the
U.S. Department of Education hasn't yet distributed all of the
money in the stimulus, we are seeing signs that we are meeting
that goal of preserving jobs of teachers and other educators.
We are collecting data on the number of jobs preserved. We can
point to several districts around the country where the
stimulus funding has made a dramatic difference already.
Because of ARRA, Los Angeles Unified School District averted
almost 3,800 layoffs; in New York, it is 14,000 jobs; 139
teachers kept their jobs in Seminole County, Florida; in
Boston, the teacher union leaders say the stimulus money
ensures that the city won't lay off any teachers; and the
Alabama State superintendent has said the stimulus money will
help avert all layoffs in his State.
I am confident that just about all of the 15,000 districts
around the country will be using stimulus money to preserve
jobs that otherwise would have been lost or to create jobs they
never would have been able to add if they didn't receive money
from ARRA.
Before the stimulus, we were headed for an education
disaster. With it, we have largely avoided that catastrophe and
now must also work to continue to improve student achievement.
I am convinced we have to educate our way to a better economy.
POLICY COMMITMENTS UNDER ARRA
Through ARRA, States are promising to make commitments on
policies that we consider to be essential to reform. They will
improve the effectiveness of teachers and work to make sure the
best teachers are in the schools that need them the most. They
will improve the quality of their academic standards so that
they will lead students down a path that truly prepares them
for college, the workforce, and global competitiveness.
These standards need to be aligned with strong assessments.
I am particularly concerned that these assessments accurately
measure the achievement of English language learners and
students with disabilities.
Under the third assurance that Governors must make under
the State Fiscal Stabilization Fund program, States will commit
to fixing their lowest-performing schools. Finally, they will
build data systems that track student performance from one year
to the next, from one school to another, so that those students
and their parents know when they are making progress and when
they need extra attention. This information must also be put in
the hands of educators so they can use it to improve
instruction.
SCHOOL REFORMS IN EXTENDING SCHOOL DAY AND YEAR
Another key ingredient to reform is to add more time for
instruction. I grew up in my mother's after-school program in
Chicago, so I know firsthand the critical importance of after-
school and summer programs. That is why we are asking districts
to consider using Recovery Act funding, as well as Title I
funding, to extend the school day, the school week, and the
school year. And we are already seeing real innovation. In
places like Cincinnati, that innovation is actually beginning
this summer. They are adding what they call a fifth quarter and
keeping students for a month after school gets out to continue
to drive reform and keep teachers employed. This is a key
component of our school turnaround strategy, because we know
that students who are struggling need more time to catch up.
Through ARRA, we will be rewarding States, districts, and
nonprofit leaders that have dedicated themselves to moving
forward in each of these areas of reform. The $4.3 billion Race
to the Top Fund will reward States that are making commitments
to reforms so they can push forward and provide an example for
others. The $650 million What Works and Innovation Fund will
provide grants to districts and nonprofits to scale up
successful programs and evaluate promising practices. My
Department expects to issue invitations for applications this
summer and start to award grants late in the fall.
FY 2010 EDUCATION BUDGET REQUEST
With ARRA as a foundation, we have submitted a fiscal year
2010 budget that will build on the Recovery Act and advance all
of the President's priorities. Overall, President Obama is
asking for $46.7 billion in discretionary funding for the
Department, an increase of $1.3 billion over the comparable
2009 level.
I want to highlight our request in several important areas:
investing in early childhood education, improving the pay and
professional development of teachers, turning around low-
performing schools, and ensuring that college students have the
financial aid and student loans they need to complete college.
IMPROVING TEACHER QUALITY AND LOW-PERFORMING SCHOOLS
In K-12 education, we are requesting important investments
in two of the key priorities identified under the stimulus:
improving the quality of our teachers and turning around low-
performing schools.
In other countries, the top third of college graduates
enter the teaching workforce. Too often, here in the United
States, our best choose other professions. We need to change
the way we promote and compensate teachers so we can attract
the best and brightest into the profession by rewarding
excellence and providing supports that enable success.
ADDRESSING THE NATION'S DROPOUT PROBLEM
As for turning around low-performing schools, we know that
too many of our schools are letting our children down. In too
many places, achievement is low and not improving. For example,
in approximately 2,000 high schools, 60 percent of the entering
freshman class will drop out by the time they are supposed to
be seniors. That collective loss of human potential and the
long-term negative impact on our economy are both staggering.
Under ARRA, we will ask States to identify the bottom 5
percent of their schools. In our fiscal year 2010 budget
request, we want to give them the resources to fix those
schools, with a strong focus on dropout prevention in the so-
called ``dropout factories.''
This dropout challenge is a national plague that I think
strikes a real blow to where we are trying to go as a country.
Half these schools are in urban areas, 20 percent are in rural,
and 30 percent are in suburban. So this is a real national
problem.
And a recent study from the Alliance for Excellent
Education came to the conclusion that if all the students in
the class of 2008 had graduated, the benefits to our economy
would have been an additional $319 billion in income over their
lifetimes. And if we don't change, over the next decade another
12 million students will drop out, and the cost to our economy,
to our Nation is $3 trillion. So the economic impact, as well
as the loss of human potential, is absolutely devastating.
RESOURCES FOR LOW-PERFORMING SCHOOLS
Our budget includes $1.5 billion for the Title I School
Improvement program. That is almost a $1 billion increase over
last year. When that amount is added to the $3 billion the
program received in the ARRA and the $545 million in fiscal
2009 funds, we have more than $5 billion to help turn around
low-performing schools.
I am talking about dramatic changes here. I won't be
investing in the status quo or in changes around the margins. I
want States and districts to take bold actions that will lead
directly to improvements in student learning and better
outcomes. I want superintendents to be aggressive in taking the
difficult step of shutting down a failing school and replacing
it with one they know will work. When we talk about 2,000
schools producing half of our Nation's dropouts, and 75 percent
from the minority community, that is the number we have to get
our hands around and really challenge in a substantive way.
NATIONAL TEACHER RECRUITMENT CAMPAIGN
To improve both the quality of teachers and the support
they receive, we are requesting $517 million for the Teacher
Incentive Fund, including $30 million for a National Teacher
Recruitment Campaign. This program is designed to improve the
quality of the teaching workforce using innovative professional
development and compensation systems as a core strategy.
I want to be clear that I want the grants awarded in this
program to be a cooperative effort between districts and
teachers. The President has often said that he believes changes
to the teaching profession must be made by working with
teachers, not by doing things to teachers. The chance for real
collaboration here is remarkable.
Chicago was one of the first 34 projects to receive a grant
from this program. Like many others, we worked closely with our
teachers to create the program. In fact, a team of our best
teachers actually gave the program shape and chose the design
framework that became our foundation. Together, we created a
program that emphasized improving professional practices of
teachers, identifying what it takes to make teachers better,
and those teachers and those schools that have improved.
TEACHER INCENTIVE FUND CHANGES
One important change that we are requesting to the Teacher
Incentive Fund would allow districts to reward all employees of
a school for helping to improve student achievement. Students
excel and thrive when all adults in the school work together.
The custodians and the cafeteria workers also need to be
rewarded when the students in their school succeed. When every
adult in a school building collaborates to create a culture of
high expectations, magic happens for children.
STRIVING READERS PROGRAM
In addition, we are seeking $370 million for the Striving
Readers program. The program now works to improve the literacy
skills of adolescent students who are reading below grade
level. We will dedicate $70,000,000 for that purpose, almost
double the amount in the fiscal year 2009 budget.
YOUNG READERS PROGRAMS
With the remaining $300 millions, we will create a
competitive grant program to support districts that create
comprehensive and coherent programs that address the needs of
young readers. These programs ensure students learn all of the
skills they need to become good readers, teaching them
everything from phonemic awareness to reading comprehension. We
intend to build upon the successes and lessons of the Reading
First program while simultaneously fixing that program's
problems.
ESEA, TITLE I AND IDEA STIMULUS FUNDING
I would like to say a word or two about the two largest
programs for K-12 students, the Title I program and the
Individuals with Disabilities Education Act. Both Title I and
IDEA Grants to States programs received dramatic funding
increases under ARRA. Title I received $10 billion for grants
to districts, in addition to the $3 billion for the school
improvement program, while IDEA Grants to States received $11.3
billion. That is almost as much as the IDEA Grants to States
program received in fiscal year 2009. We are working closely
with districts to ensure that they spend this money wisely and
not put it into programs that they won't be able to sustain
when the money has run out.
I would also like to note that both of these programs
didn't receive the increases they otherwise might have in the
fiscal year 2010 request because of the amount of money
provided under ARRA and the period of availability. We hope to
resume our commitment to funding increases for these programs
once the stimulus money has expired.
In the short term, we need increased funding for school
turnaround efforts. The students attending these schools cannot
afford to wait. We are at a crisis. More of the same in our
dropout factories will not help our children succeed and beat
the odds. It will only ensure that we educators actually
perpetuate poverty and social failure. We have too many
examples of what does work and what is possible all around the
country to continue to allow this devastating failure to exist.
EXPANSION OF PRESCHOOL PROGRAMS
In fiscal year 2010, we will also be making investments in
early childhood programs. Under Title I, we are requesting $500
million, to encourage districts to use the program's money to
expand preschool programs. This money will help build one piece
of the comprehensive early childhood programs that President
Obama has proposed. It is necessary to schools serving a Title
I population, which will benefit the most from early childhood
education.
EARLY LEARNING CHALLENGE FUND
The budget also includes $300 million to start the Early
Learning Challenge Fund. The program's initial goal is to help
States build a network of services that will maximize the
investment in early childhood education. Expanding access to
high-quality early childhood programs is one of the best
investments we can make. All of these changes will help push
school reform in K-12 schools.
COLLEGE ACCESS AND COMPLETION BUDGET PROPOSALS
We also have significant and important policy changes for
higher education. The Recovery Act made an important
downpayment on our plans to expand student aid. In addition to
more aid, we want to make sure that more students are not just
attending college but graduating. And in our proposal is a $2.5
billion request over 5 years for a college completion and
access grant. The stimulus bill provided $17.1 billion so we
could raise the maximum Pell award from $4,850 to $5,350.
PROPOSED CHANGE TO MANDATORY PELL GRANT
Now, in the fiscal year 2010 budget, we propose important
and permanent changes to ensure students have access to Federal
grant aid and loans. The first thing we propose is to move the
Pell grant program from discretionary to a mandatory
appropriated entitlement.
Second, we propose to link the increase in the Pell maximum
grant to the Consumer Price Index plus 1 percent every year,
which will allow the maximum grant to grow at a higher rate
than inflation so it can keep up with the rising cost of
college.
I am grateful for the tremendous work that the
appropriators have done to fund annual increases for the Pell
grants, particularly in the last 4 years. But even with their
dedication, the maximum grant has not kept up with the rising
cost of college tuition. By making the Pell grant program
mandatory and indexing annual increases to the CPI, we are
ensuring that students will know that their Pell grant will
increase at the same rate as their tuition. This will give them
the assurance that they will have the tuition assistance they
need to make it through college.
This is absolutely a major financial commitment. We are
able to pay for this change in part by streamlining and
improving the Federal student loan program. We will move the
loans over time from the Federal Family Education Loan program
to the Direct Loan program, making loans more efficient for
taxpayers and freeing up money for Pell grants. In doing so, we
can dramatically expand access to college without going back to
taxpayers and asking them for another dollar.
BUDGET PROPOSALS SAVINGS OFFSETS
In closing, I would like to note that this budget makes
tough decisions. President Obama asked all Cabinet agencies to
examine their budgets, line by line, and to identify programs
that are ineffective or too small to have significant impact.
Our student loan proposal saves more than $4 billion annually.
In addition, we are proposing to eliminate 12 programs,
creating an additional savings of $550.7 million.
Even though we recommend cutting these programs, we remain
absolutely committed to their goals. We are eliminating the
$294 million State grant program under the Safe and Drug-Free
Schools and Communities program, because several research
studies have found that the program is ineffective. But we
remain committed to fighting drug use and stopping violence in
our schools, which is why we are recommending a $100 million
increase in spending for the national activities under the Safe
and Drug-Free Schools programs. Even as we are proposing to
eliminate the Even Start program, we will continue to support
the program's focus on comprehensive literacy programs through
the expanded Striving Readers program and Early Reading First.
These program eliminations show that our fiscal year 2010
budget is a responsible one. It invests in our country's future
economic security while also making tough decisions to
eliminate programs that aren't working.
I appreciate the opportunity to discuss our fiscal year
2010 budget. I look forward to your committee's questions.
Thank you so much, Mr. Chairman.
[The information follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
NCLB REQUIREMENTS FOR SPECIAL NEEDS STUDENTS
Mr. Obey. Thank you.
Mr. Tiahrt.
Mr. Tiahrt. Thank you, Mr. Chairman.
We had a little discussion earlier about No Child Left
Behind. I didn't support it. I thought there were better
methods of achieving the same goal. And I have seen some really
dramatic problems with the legislation, and let me give you an
example in rural Kansas.
There is a young man named Joshua in a high school, in
Chaparral High School. He struggles with his grades. He suffers
from Tourette's Syndrome, which he is on medication for. His
parents were called in to the school, where the superintendent
informed them that he needed to be removed from school. And
they suggested he go to a nearby small town and enroll in a
learning center.
The parents didn't know how to react to all this. They
ended up taking him down to the center. They found out that 40
other students from that high school were also enrolled in the
learning center, all of whom were struggling with their grades.
Since that time, there have been several other students come in
to that center.
IMPACT OF REQUIREMENTS ON SOME LEAS AND SCHOOLS
What it appears to be is that, because of the demands of No
Child Left Behind and the stringent percentages of students
that are special-needs students, many school systems cannot
meet that small percentage. And there is no variable system to
allow them to accommodate these students, and so principals
simply force them out of the school.
These are the small high schools in rural Kansas, and they
really have very little places to go, very little choices. So
this child has to carpool with other kids and travel a
significant amount of distance to go to an alternative learning
center so that this school system can abide by No Child Left
Behind.
Part of this reform has to take into consideration that, in
many areas, some schools systems have actually specialized
because they are compassionate and they want to help these kids
achieve their greatest potential. But because of the rigidity
in the program, we can't accommodate them. And so, you know,
they fail on these five categories and the two major
categories--math and reading. It just takes one and the whole
school system fails.
So we have instituted a program that forces students out of
schools. And I don't think that is your goal. It is not my
goal. And it is certainly not fair to Joshua. He comes from a
good family, pillars in their community, a well-respected
family. He is the third child. The other two kids are doing
very well and moving on to higher education. But here he is
left without the high school experience, without the
opportunity, because of a system that we put in place here in
Washington that I disagree with.
NCLB GOALS, ACCOUNTABILITY AND FLEXIBILITY
How can we change the system so that we don't leave
children behind? And can't we find some flexibility here? And
accountability is good; I don't disagree with the concept. But
I don't think it should be so inflexible that we can't
accommodate kids like Joshua.
Secretary Duncan. The NCLB reauthorization is probably a
couple-hour conversation. I will try to keep my remarks pretty
quick.
And, just to give you context, obviously I lived on the
other side of the law for 7 1/2 years, so I have my own strong
opinions. But I am in the midst of traveling to 15 different
States and meeting with teachers and meeting with parents and
meeting with children and principals to really get the pulse of
the Nation to figure out what folks think is working, and what
is not.
Let me start with what I think is working. I think the idea
of accountability, the idea of disaggregating data and shining
a spotlight on the horrendous achievement gap between white
students and African American and Latino students, I think that
is very important. And, as a country, we can no longer sweep
that conversation, that tough conversation, under the rug. And
we want to keep that front and center.
There are also numerous challenges. As Chairman Obey said,
one of the biggest challenges was a dramatic underfunding of
the law. And with his leadership, now there is a step in the
right direction, unprecedented steps in the right direction, to
add unprecedented resources to helping students and schools be
successful.
Big picture, I will just say what I think fundamentally
happened--I don't know if it was intended or unintended, it was
wrong. I think any time you are trying to manage, whether it is
a business or an education system, locally or nationally, you
have to be very thoughtful about what you manage loose and what
you manage tight. And what NCLB did is, it was very loose on
the goals. You have 50 different States, 50 different goalposts
all over the map. And, due to political pressure, many of those
got watered down to the point that we were lying to children.
Where they were very tight and very prescriptive is in
terms of how you try and succeed, how you try and improve. But
when I was in Chicago, I didn't think all the good ideas came
out of Washington. And now that I am in Washington, I know all
the good ideas don't come out of Washington.
What I want to do is fundamentally flip that on its head. I
want to think about a high common bar, common standards,
rigorous goals that we all have to hold ourselves accountable
for, that really provide creativity and flexibility at the
local level; hold folks accountable, but give them their chance
to innovate and be successful.
INCREASING GRADUATION RATES
Secondly, I am a big believer in looking at outcomes. And
we ultimately have to help more students graduate. We can't
push the special education students out the door. We can't hide
from those challenges.
And I want us to think about what we do to dramatically
improve our graduation rate. When we talk about 30 percent of
our Nation's students dropping out, the economic cost to our
country, the loss of human potential, is absolutely
unacceptable. And, as you well know, a couple of decades ago,
there actually was an acceptable dropout rate. You could drop
out and go get a job and support a family and own your own home
and make a good living. Today, every child who drops out is
basically condemned to social failure.
And we have to stop pushing students out. We have to start
finding ways to keep those students in, and reward those
schools and those school districts that are working with the
hardest-to-serve students and keeping them on track.
Mr. Tiahrt. Thank you. I know our time is limited so I will
wait for future comment. Thank you.
Mr. Obey. Thank you.
Ms. DeLauro.
EVEN START PROGRAM--FAMILY LITERACY SERVICES
Ms. DeLauro. Thank you very much, Mr. Chairman.
Welcome, Mr. Secretary. It is another opportunity to be
with you, and I appreciate your testimony before the Budget
Committee some time ago.
You have an extraordinary commitment to education and to
our children, as does the President, which is why, quite
frankly, I am puzzled. I am puzzled by the Administration's--I
will put it this way--Bush-inspired elimination of the Even
Start family literacy services. Ninety-one percent of families
in the program are at or below the poverty level. Ninety
percent of the parents in the program do not have a high school
diploma or a GED. This program serves children, and it serves
their parents and those who are in the greatest need.
Even with the decline in funding that we have seen through
years, I will be specific and parochial about how the program
continues to thrive in my State of Connecticut. We have had a
Wesleyan University study of the Middletown, Connecticut, Even
Start Program. Parent outcomes showed positive results, showed
that Even Start parents are more likely than a control group to
advocate for their children's educational needs and discuss
educational progress with their kids. Even Start parents were
also found to have higher educational aspirations for their
children.
EVEN START EVALUATIONS
Your budget documents justified a cut by citing an
evaluation using data now 10 years old and based on a program
reformed 9 years ago. Let me just ask you why you took a page
out of the Bush budget proposals and proposed to eliminate this
critical program.
Secretary Duncan. We looked at three national evaluations,
and these three separate national evaluations reached the same
conclusion: that Even Start did not result in significantly
greater gains for children or adults participating in the
program than for nonparticipants.
STRIVING READERS PROGRAM
We also added money to the Striving Readers program, $370
million, to try and help both the young children and adolescent
literacy.
So, again, we are absolutely committed to the goal. But
that program, from a few different national evaluations, didn't
seem to be producing the results that we wanted.
Ms. DeLauro. Well, I would have to say to you that to
suggest that Even Start services can be replaced by either
adult ed funding or Title I preschool ignores, I think, the
tenets and the structure of the program.
I am not about protecting programs. I mean, I think if
programs are not working, I think we ought to, you know, shut
them down. But I am about helping those that need some sort of
a comprehensive approach for their entire family. And, you
know, adult education is one component of family literacy.
EARLY LEARNING CHALLENGE FUND
Secretary Duncan. Let me be clear. It is not just adult
data. We add up to $300 million for the Early Learning
Challenge fund. So there is a significant pool of money to make
sure that we are getting students off to a good start and
getting those early literacy skills intact.
COMPREHENSIVE APPROACH TO FAMILY LITERACY
Ms. DeLauro. Uh-huh. Well, I think that if you take a look
at how you impact the lives of children, I think that you would
concur with this. And this is not something that I have
invented. I think you would hear from people who have spent a
lifetime in education, Dr. Heckman and others, who are very
clear about the role of parents and their influence on their
children.
And unless, quite frankly, we deal in a comprehensive way,
and whether that is literacy, whether that is economic concerns
and jobs, et cetera, if we do not address the needs of parents
and their literacy skills, then, quite frankly, we are not
going to really be making a difference in the lives of these
children.
Secretary Duncan. I appreciate your concerns.
AFTER-SCHOOL PROGRAMS AND LENGTHENING THE SCHOOL DAY
Ms. DeLauro. Okay, thank you.
Let me then ask you about after-school programs, another
area. I was a teacher in the after-school programs many, many
years ago, so I am a strong believer in these efforts.
And I know you are supportive of this, but how will the
Administration demonstrate its support for after-school when it
has only proposed level funding for the 21st-Century Community
Learning Centers program? And that is the only Federal funding
stream, as far as I know, that is dedicated to after-school.
Secretary Duncan. Yeah, obviously, this is a really
important issue. And when I talk to students, this is the line
that usually gets booed, not applause. But I think we have to
think dramatically differently about time. We need our days to
be longer, we need our weeks to be longer, and we need our
school year to be longer----
Ms. DeLauro. I agree.
Secretary Duncan [continuing]. And that after-school
timeframe is hugely important.
FUNDING SOURCES TO EXTEND LEARNING OPPORTUNITIES
There are a number of different funding sources for this in
the budget. You are starting to see some really creative
things. You have, obviously, the stimulus dollars that can be
used to lengthen time, after-school, during the summer. You
have Title I dollars. This is a great, great use of these
funds. I worry particularly about children who come from poor
families who aren't being read to at home. That is a huge use
for these increased Title I dollars, to do more after school.
And then there are significant competitive grants: again,
the $4.3 billion Race to the Top Fund and the $650 million What
Works and Innovation Fund. So there are multiple pools of money
for States and school districts to start to think very
differently about time.
And, again, just one quick example. This summer,
Cincinnati, using stimulus dollars, is keeping school open a
month longer. I think that is a great step in the right
direction, and you are going to see lots of other folks do
that. So there are unprecedented resources available for
schools to think about longer days, longer weeks, longer years.
We have put out clear guidance with all of our funding that
we think this is a very important use of money and a great
strategy to help students who are historically low-performing
and come to school from a disadvantaged background. It is a
great way to level the playing field. So we are going to
continue to provide incentives for this, to encourage this, to
highlight those best practices. And there has never been more
flexible money to use to extend learning time.
Ms. DeLauro. My time has expired. Mr. Chairman, thank you.
And I hope we will have a second round.
Thank you very much, Mr. Secretary.
Mr. Obey. Mr. Rehberg.
Mr. Rehberg. Thank you, Mr. Chairman.
RURAL EDUCATION CONCERNS
And I appreciate you having traveled to Montana just 6 days
ago. I am a little disappointed you are not wearing your War
Bonnet blanket that you were given.
Just to put it into perspective, both my grandmother and
mom were teachers and came from Landyer, which is where you
were. And so you know particularly the problem that exists
within education in rural communities.
I am, I guess, a little surprised and perhaps a little
disappointed in the budget presentation as we see it as it
relates to the rural educational needs. While I may have had
heartache with many areas of No Child Left Behind, I found the
Bush Administration at least amenable to flexibility. And I
hope that you will be, as well, as you manage many of the
programs within the budget.
But, in particular, the shift from formula to grants within
the budget is something that scares me a bit. Because coming
from a rural area like Montana, we find that we don't have
maybe the level of expertise to have grant writing as other
areas that have economy of scale. So I would like to point that
out to you, in particular.
RURAL EDUCATION CAUCUS
And I have a letter that is outside. I have the preliminary
report from the Rural Education Caucus, just talking a little
bit about your budget. I formerly chaired the Rural Education
Caucus and turned that over to other more capable individuals.
But I would like to have this presented to the record, as soon
as it gets here.
TRIO PROGRAMS AND POSTSECONDARY SUCCESS
Mr. Rehberg. Some of the words you used in your
presentation were ``perpetuate poverty and social failure,''
and not just attending but graduating from college.
Having traveled to now the Cheyenne reservation and seeing
the kinds of students--Mr. Chairman, I just might point out
that your numbers were impressive, but our unemployment rate on
the Cheyenne reservation is 70 percent. That is 7-0. And that
is something that definitely concerns us.
One of the programs that is very successful in Montana, may
not be so much in other areas, is the TRIO program. And if you
want to do something to not perpetuate poverty and social
failure, and not just attending but graduating from college, it
really is important not to necessarily create a mandatory
program in Pell grants but to fund appropriately programs like
TRIO, which are a more holistic approach to providing
assistance to graduating seniors going on to college.
And just real quickly, I looked up the numbers. Nationwide,
the percentage of low-income high school graduates enrolling in
postsecondary education is 24 percent. In Montana, it is 73
percent. So this is really a program that has given us an
opportunity to take our kids and give them something more so
that they can compete when they get to college.
And it is more of the holistic approach that I would hope
that you would seriously take a look at and see that perhaps
these funding levels aren't necessarily appropriate for the
assistance of rural education.
And I will give you a chance to respond.
CHEYENNE RESERVATION IN MONTANA
Secretary Duncan. Let me just start. I am learning so much
every day about, you know, not just there but West Virginia and
Vermont. But let me tell you, my visit to Northern Cheyenne, to
the reservation there, is something I will never forget. And I
have been in some pretty tough areas in my life and worked in
some pretty tough areas, and the level of desperation, the
level of poverty, was heartbreaking.
And the high school I visited--this is not a scientific
study, but the teacher said, to the best of their knowledge,
they had had one child in the past 6 years graduate from
college--one. And as I talked to the students, they were smart,
they were committed, they wanted more, and they were
desperately pushing against expectations. They repeatedly told
me that they are being told on multiple fronts that they are
not good enough and they can't make it, and they are fighting
that.
So let me tell you, there are lots of areas of this country
where we need to improve the quality of education, but that is
not one that I am going to forget. That is one that is very
personal to me. And I am going to figure out, not just there
but in other places, how we help children who have been trapped
in--you know, I can't even imagine 70 percent unemployment. I
am still trying to get my head around that number; it is almost
incomprehensible.
We have to do something there. And, again, I am convinced
the only way we get to there is through better education. So I
don't have all the answers, but I want you to know I am
absolutely committed to trying to make a difference there.
TRIBAL COLLEGES
Mr. Rehberg. And I appreciate your recognition of the
tribal college issue, as well. We are very proud of the fact
that I think we are the only State that has a tribal college on
each of the seven reservations.
Secretary Duncan. Yeah. And it is pretty remarkable
leadership. I met with a number of those tribal college
presidents.
TRIO AND GEAR UP PROGRAMS
I will just say quickly that I am a big fan of the TRIO
program, a big fan of GEAR UP. We haven't talked about dual-
enrollment programs, where high school students start to take
classes on college campuses and get exposure there. And the
more we can bridge that divide and help students really believe
that college is a possibility for them, that is hugely
important.
And we have too many children around the country, including
those I met there, who are smart enough, who are working hard
enough, but are being told college is not for them, it is a
different world. And we need to break through that
psychological barrier and raise our expectations dramatically.
Mr. Rehberg. Thank you.
Thank you, Mr. Chairman.
Mr. Obey. Ms. Roybal-Allard.
PROPOSED EVEN START ELIMINATION AND FAMILY LITERACY
Ms. Roybal-Allard. Thank you, Mr. Chairman.
And welcome, Mr. Secretary.
First of all, let me associate myself with the concerns
that were raised by Congresswoman DeLauro about the elimination
of the Even Start program, particularly since it has been based
on this 2003 study in which the evaluators themselves said, and
this is a direct quote: ``Care should be given in applying the
findings to Even Start as a whole.'' And then, furthermore, a
2007 Pennsylvania State University study found that the 2003
evaluation had inherent design flaws. So eliminating a program
as important as this based on questionable studies I think is
something to be concerned about.
And also, although I realize money is being shifted to
other places, the point that Ms. DeLauro made I think is very,
very valid. And those programs do not provide family literacy.
And family literacy, as you know, is key to having parents
involved with their children. And when parents are involved,
the research has shown that children succeed at a much higher
rate.
So I just want to associate myself with the comments that
were made by Ms. DeLauro, in also hoping that you will take
another look at this proposal.
EDUCATION TECHNOLOGY FUNDING
Another concern that I have about the budget deals with
education technology funding. Now, President Obama has spoken
at length about the importance of equipping our schools, our
community colleges and public universities with 21st-century
classrooms. The Enhancing Education Through Technology Grant
program was designed to achieve those very goals. Yet, the
budget cuts this already underfunded program from $269 million
to $100 million.
Now, while it is true the program receives $650 million in
the stimulus bill, there is a problem using that as the
rationale. First of all, the fact is that the stimulus was
intended to supplement and to not supplant existing funding.
Furthermore, the drastic cuts put the only significant
technology program that the Department of Education has at a
terrible disadvantage, because, by funding the technology
program at $100 million in fiscal year 2010, you are lowering
the baseline for future funding. And it could take years for
this program to regain even its 2009 funding level of $269
million.
Can you explain the rationale for such a dramatic cut in
funding for education technology, especially now when it is
more needed than ever?
Secretary Duncan. Again, I mean, you hit on both the
challenges and the opportunities. But when we have, as you have
stated, $650 million in new money--unprecedented increases for
education technology. There is a huge influx of money to go
across the country to folks to work very, very hard in this
area. And we have never seen that kind of support, ever, for
education technology.
Ms. Roybal-Allard. So you are basically supplanting, then,
in other words. And the program, as I said, is going to be put
in a terrible disadvantage in the future, because that then
becomes the baseline.
Secretary Duncan. I understand the concern. Again, there
was two to three times as much money going in through the
stimulus package than this program has ever seen before.
Ms. Roybal-Allard. Okay, but that doesn't address the
problem it creates in the future.
Secretary Duncan. No, I understand that challenge. I
totally understand that challenge.
SAFE AND DRUG-FREE SCHOOLS AND COMMUNITIES STATE GRANTS
Ms. Roybal-Allard. Okay. The Safe and Drug-Free Schools and
Communities program provides very effective, research-based
approaches to drug abuse and violence prevention. And the
program reaches about 37 million students in every school
district across the United States.
Now, the President's budget eliminates the $295 million
State grant program and replaces it with a much smaller $100
million competitive grant program. And it is my understanding
that the Department justifies eliminating this program on an
old 2001 study.
Many changes have been made to this program in the last 8
years. And not only will there be less money available for
school drug programs--which, I might add, are badly needed. We
definitely have a drug and alcohol problem with our young
people. But by making it competitive, the result will be that
some school districts will be left without these vital funds,
because they will not be able to compete and get that money to
support their programs.
And in cases where schools were getting just a small
amount, what they are able to do is use that small amount of
Federal money to leverage other State and local funding. So
they are going to lose that ability.
So, again, what is the rationale for limiting the scope and
the reach of this program? And what will be done to help those
schools that will not be able to compete and get the money and
will no longer be able to leverage even a small amount of
Federal money in order to help them to be able to have these
drug prevention programs in their schools?
Secretary Duncan. I really appreciate the question.
Obviously, these are huge, important issues, and continuing to
make sure our schools are violence-free and drug-free is hugely
important. And, Mr. Chairman, we made tough cuts. They are hard
and controversial and not easy, and I understand that.
It wasn't just a 2001 study, just to be clear on the facts
base. There was a 2007 study, as well, that talked about these
programs not really making a significant difference. That is
much more current than the 2001 study.
And what we really found was that money that was trickling
out to States wasn't making a big difference. And we want to
get that money directly to schools and into school districts,
and to be much more tangible, much more hands-on with students.
And that was the shift in strategic focus. We remain absolutely
committed to the goals.
Mr. Obey. Let me explain. We have four votes coming up. And
the Majority Leader has announced that, in contrast to recent
practice, he is going to hold these votes to a tight timeframe.
So if we don't want to miss the votes, I would suggest that we
go over to the House now.
I am sorry, Mr. Secretary, but we are going to be stuck
over there; my guess would be for about 30 to 40 minutes.
[Recess.]
Mr. Obey. Mr. Secretary, I know this is a wonderfully
productive use of your time, but we will try to screw things up
again in about 10 minutes.
So, having said that, Ms. McCollum.
Ms. McCollum. Thank you, Mr. Chair.
NATIONAL EDUCATION STANDARDS AND GOALS
And, Mr. Secretary, it is good to see you again. When you
were before the Budget Committee, we had an opportunity to
speak a little bit about national standards and national goals
development. And I know that you are working with NCSL and
school boards and superintendents and parents all over across
the country to work on that. So I hope to talk to you more
about that and how my concern that is going to come up shortly
about funding is going to fit in.
NATIVE AMERICAN STUDENTS
But I do want to thank you for your sincere acknowledgment
of what our tribal schools need, as well as, as you become even
more immersed in this issue for our young children and leaving
truly no one behind, the needs that many Native American
children face in our urban and suburban settings, as well as
what you have seen on the reservations.
I was just at Mille Lacs and Leech Lake, where I saw great
things going on in school buildings that were second-rate, but
the hearts of those kids were first-rate in being there and
learning, and so were their elders and their community behind
them 100 percent.
STATE BUDGET DEFICITS AND ACCOUNTABILITY
I want to talk to you for a second about what I consider
becoming near a national security issue, and that is the
economy and the role of education in the economy. And, as the
economy has worsened, I am afraid we are seeing opportunities
for education, for many of the things that you want to do, and
President Obama and I and the parents in my district, slip
through our fingers. That is, as I said, a national security
issue, not only as, I think, making us being able to compete in
this world, but also for keeping our democracy vibrant and
strong and a beacon for other countries to look at.
The Center on Budget and Policy Priorities recently issued
a paper on Federal fiscal assistance for State governments. It
has seen what the recovery package has done. It has enabled
States to not decrease their budgets quite as much as they
might have with the shortfalls that they are seeing. In other
words, it is smaller cuts for education than what would have
been.
And I am concerned about this, because if you look at what
is going on in 46 of the States, they have deficits for fiscal
2010 and beyond. The gaps total $133 billion for 45 States, and
they are estimating the size of these gaps could grow.
Minnesota alone has a $654 million mid-year budget deficit.
ACCOUNTABILITY FOR USE OF RECOVERY FUNDS
So what I am concerned about is that Recovery funds are
really supplanting regular education funds. This Congress made
a decision not to do matching funds to give States some
flexibility. We gave governors and their departments of
education the dollars without going through their legislative
branches, assuming that these funds would be used, yes, to
maybe supplant a little, but they are being supplanted for
everything.
So how do we move forward? And I agree with Chairman Obey.
With all the goals, all the wonderful goals in this budget, and
with the money that you have planned to achieve these goals, if
we send the money to the States and they just use it to provide
basic education and still cut basic education, then we are set
up for failure, President Obama is set up for failure, but,
most importantly, our children are set up for failure.
So how are we going to hold these school districts
accountable? Where is the shared responsibility for our
children's future?
Secretary Duncan. That is a great question. And I am a
believer in both awards and consequences, and let me tell you
what we are doing at both ends of the spectrum.
First of all, in the first round of the stimulus package,
we put out tens of billions of dollars, and our staff has
gotten that money out extraordinarily quickly. We committed to
putting it out within 14 days, and our staff has been getting
it out in closer to 6 days. They have been working nights and
weekends to really respond to the urgent need.
But we also held back billions of dollars. And where we see
States playing shell games or acting in bad faith, we have the
opportunity not to put out that second tranche of money. And we
are not looking for a fight, we are not looking to be the tough
guy or the bad guy, but we are absolutely prepared to do that,
if necessary. So we have a real significant stick there.
Secondly, we talked about unprecedented discretionary
resources: $4.3 billion for the Race to the Top Fund, $650
million invested in the What Works and Innovation Fund. And
where we see States playing games or acting in bad faith and
doing the wrong thing by children, they will basically
eliminate themselves from that competition.
So they have a chance to bring in, on top of unprecedented
stimulus resources, a chance to bring in hundreds of millions
of dollars into their States if they are creative, if they are
innovative, if they are pushing the status quo and challenging
the status quo. But if they are doing the wrong thing, they
could lose out in the second set of stimulus money, and they
would absolutely put themselves at huge risk, huge jeopardy, of
just being eliminated from the competition for discretionary
dollars.
So I think we have real carrots and real sticks to try to
encourage States to act in good faith and do the right thing by
children.
Ms. McCollum. Thank you, Mr. Chairman.
Mr. Obey. We now have another vote going on with 12 minutes
left.
Mr. Moran, why don't we take you? And then I am afraid we
will have to go vote again.
Mr. Moran. Who is in charge of this place anyway?
Mr. Obey. Nobody.
Mr. Moran. Okay.
EDUCATION FUNDING DISPARITIES
I want to ask you, on a macro issue, Mr. Secretary, related
to the geographic and economic disparity in our public school
system, bearing in mind that what the Federal Government does
is at most capacity-building and gap-filling. It is a
relatively small fraction of the public education budget. But
some trends have been occurring that have been exacerbated in
the last several years.
One is geographic. It is clear that the best, from an
academic and creative standpoint, students in much of the
heartland of the country, they are moving. They are moving to
the coast, the east or west coast, to what Richard Florida
calls the ``creative class communities.'' They prefer, you
know, Metro and the coffee shops and so on, or the principal
suburbs. You are aware of that geographic disparity. And it is
causing a major employment and economic potential gap.
But the other problem is an economic one, and it is really
based upon the way we fund public education. As you very well
know, we are too reliant upon property taxes. The problem there
is that the parents who have the most at stake in our public
school system are the least likely to own much property. And so
they really are kind of powerless in terms of putting adequate
resources into the public school system.
Those who have the money are either retired, or they are in
their fifties or whatever, they have accumulated some wealth,
so they have substantial property, or they are wealthy enough
that they send their kids to private school. And we are seeing
that over and over again, particularly in inner-cities and some
of the exurban areas. There is a lessening of the political
support for adequate investment in education.
So, of all the things that we do, perhaps the best thing we
could do is to try to restructure our national system for
funding education. It is regressive now; there is a built-in
perverse incentive. And it is one of the reasons why, in terms
of comparativeness to the rest of the world, we tend to be
dropping each successive year in terms of our global
competitiveness and the preparation of the workforce.
So I would like to get some thoughts from you, because I
have heard you express yourself before and you, I think, would
have some useful suggestions. But I would like to know if the
Administration has thought about taking this issue on.
Secretary Duncan. It is another long, long conversation,
but this issue is very personal for me. I come from a State,
Illinois, and my numbers may not be exactly right, but we were
48th in the amount of money going to education, so we were
virtually dead-last. And we were 43rd in the disparities
between wealthy districts and poor districts. And I was at the
poor end of that. I worked in a district that was 90 percent
minority, and 85 percent of my students lived below the poverty
line.
EQUALIZING ASPECT OF EDUCATION
And when the children of the rich get dramatically more
spent on them than the children of the poor, it exacerbates the
great disparities and outcomes. I think public education, at
its heart, should be the great equalizer. And every child,
regardless of whether he or she is wealthy, poor, black, white,
Asian, Latino, it doesn't matter, every child should have a
chance to get a great education.
And money doesn't begin to answer all our problems, and we
have seen lots of money spent on things that don't make sense.
But it is interesting, in every wealthy district they seem to
spend a lot of money on education, and there is a value there.
And it needs to be spent well.
And so, this is one that I think we have to really think
about. And I don't have answers today. You know, our folks are
thinking about it and looking at it. But when we are
contributing, when we are perpetuating a system of haves and
have-nots, I think that is not the principle upon which our
country is based and that is not the point of public education
in our country. And we need to be very, very thoughtful about
what we are doing to give every child the chance to have a
great education.
TAX REMEDIES VS. PROGRAM PROLIFERATION
Mr. Moran. Yeah. Well, I hear you, and obviously no one
could disagree with you. But I think if we were to reassess
this whole situation and come up with a far-ranging plan that
addressed it from a tax standpoint, it might be the most
important thing we could do, instead of this proliferation of
programs trying to meet needs where it is really a marginal
improvement we can make to fixing of the underlying cause of
the disparity.
We have very little time, so I won't pursue it further or
even ask further questions, because we are going to have to go
vote. But I thank you for your thoughtfulness and your
background. We are going to have a lot of time to work
together. But I am glad you are on board.
Mr. Obey. I am going to suggest, Ms. Lee, it is futile to
try to come back here, with what is going on on the floor. We
have 6 minutes and 40 seconds left to vote. It is going to be a
short vote, so I would suggest you take 2 minutes to ask a
question. And then we will have to hang it up or we will all
miss the votes.
Ms. Lee. Okay.
MINORITY DROPOUT RATES
Well, first, welcome, Secretary Duncan. It is good to see
you again. And, again, I just want to reiterate a couple of
things we talked about at your meeting with the Congressional
Black Caucus. I serve as Chair, as you know, and one the areas
that we are extremely concerned about is dropout rates in
minority communities, especially with young African American
and Latino boys.
The statistics are African American men have a 30 percent
chance of serving in prison before the age of 30, but among
young African American men who drop out of high school it jumps
to 60 percent. And so it is just outrageous. It is astounding.
And I need to look at your budget and just look at how you are
really beginning to address this dropout rate, especially among
minority groups.
EDUCATION--A CIVIL RIGHTS ISSUE
And, finally, let me just say I am very pleased to see that
you acknowledge that education is the civil rights issue of our
time and that it is a truly effective weapon in our Nation's
long war on poverty, because you are absolutely correct. And to
have that perspective coming from your department I think is
wonderful.
Thank you.
ADDRESSING THE DROPOUT PROBLEM
Secretary Duncan. Thank you. And just quickly, as we talked
about, I think there is nothing more important we can do as a
country than dramatically reduce that dropout rate. And the
economic cost to the country and the personal loss is
tremendous.
We can identify 2,000 high schools around the country that
produce half of our Nation's dropouts and 75 percent of our
minority students' dropouts. And so what we want to do is not
tinker around the edges, not just effect incremental change. We
want to--and this is tough, tough work, but I think we have to
do it--we have to engage these tough issues in a real and
honest way. We need to fundamentally turn around, over time,
not overnight but over time, those schools and those feeder
middle schools and elementary schools.
We can identify the problem. And this has been going on for
far too long, and these children do not have a chance at being
successful when we have these kinds of dropout rates.
Ms. Lee. But, Mr. Secretary, I hope--and could you follow
up with us, or in writing perhaps to the committee, how in your
budget, what is the strategy, because I don't see this targeted
in your budget.
Secretary Duncan. $5 billion in school improvement money,
Title I--unprecedented dollars going in to help the neediest of
schools.
Mr. Obey. I am going to have to call this hearing to an
end. I will save my questions for another time, Mr. Secretary.
I apologize for the discombobulation, but that is life around
here. Thank you.
Secretary Duncan. No problem. Thank you so much for the
opportunity, and thanks for your leadership, Mr. Chairman.
[The following questions were submitted to be answered for
the record:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
W I T N E S S E S
----------
Page
Alexander, Duane................................................. 85
Besser, Dr. Richard.............................................. 199
Briggs, Josephine................................................ 85
Clancy, Dr. Carolyn.............................................. 199
Duncan, Hon. Arne................................................ 461
Ellis-Lamkins, Phaedra........................................... 30
Fauci, Anthony................................................... 85
Fitzgerald, Joan................................................. 30
Grady, Patricia.................................................. 85
Hall, Keith...................................................... 30
Hyzy, Dr. Robert................................................. 249
Kington, Raynard................................................. 85
Krugman, Paul.................................................... 4
Landis, Story.................................................... 85
Niederhuber, John................................................ 85
Pronovost, Dr. Peter............................................. 249
Rodgers, G. P.................................................... 85
Ruffin, John..................................................... 85
Sebelius, Hon. Kathleen.......................................... 369
Solis, Hon. Hilda................................................ 313
Stricof, Rachel.................................................. 249
Tabak, Lawrence.................................................. 85
Wright, Dr. Don.................................................. 199
I N D E X
----------
National Institutes of Health
Page
American Recovery and Reinvestment Act..........................175-176
ARRA and Comparative Effectiveness Research.....................154-156
Asthma and Allergy Diseases.....................................144-145
Basic Behavioral and Social Science Blueprint...................141-143
Borderline Personality Disorder.................................158-160
Chronic Kidney Disease..........................................160-161
Comparative Cost and Comparative Effectiveness in Research......139-141
Controlling High Blood Pressure and Heart Failure...............170-171
Coordination and Funding of Health Disparities Research.........171-172
Coordination of TBI and PTSD....................................143-144
Cross Cutting Research........................................... 150
Dr. Kington's Oral Statement..................................... 86-89
Dr. Kington's Written Statement.................................. 90-98
Efforts to Reduce Stroke Minority Health Disparities............169-170
Elevation of National Center on Minority Health and Health
Disparities to Institute......................................183-184
Elevation of NCMHD Institute..................................... 172
Glomerular Disease.........................................161-162, 168
Health Disparities and Equal Access Bill........................120-123
HIV/AIDS Microbicide Research...................................186-188
HIV/AIDS Research................................................ 185
HIV/AIDS Vaccine Research........................................ 186
Impact of Toxic Chemicals on Health and Development.............134-136
Improving Mitochondrial Disease Research........................166-167
Increased Support for RCMI's..................................... 173
Interacting and Engaging Minority Communities in Research........ 192
Job Estimates from ARRA Funds...................................123-124
Jobs Created with $10 Billion................................ 124
Job Estimates from Construction Funds...........................117-118
Construction Jobs Created with $1.5 Billion.................. 118
Mesothelioma Research...........................................132-134
Mitochondrial Research..........................................164-166
Neuroblastoma Research..........................................163-164
NIH Research Contributing to the Elimination of Health
Disparities...................................................181-183
NIH Research Facilities Construction Modernization............... 117
Outreach for Minorities in Research Professions.................137-139
Participation of Minorities in Accessing ARRA Funds.............178-179
Pre-Exposure Prophylaxis......................................... 188
Psychological Factors Affecting Organ Systems.................... 128
Public Access Policy............................................156-157
Scientific Priorities............................................ 152
Scleroderma.....................................................176-177
Selected Disease Research and EPSCoR............................. 145
Attention Deficit/Hyperactivity Disorder....................146-147
Autism Spectrum Disorder..................................... 148
EPSCor Consideration for ARRA Funds.......................... 149
Sickle Cell Testing.............................................150-151
Small Business Participation in NIH's Funding from the American
Recovery and Reinvestment Act of 2009.......................... 196
Stem Cell Guidance............................................... 154
Support for Nurse Scientists Faculty............................190-191
The National Children's Study..........................119-120, 153-154
The Recovery Act and HIV/AIDS Research........................... 197
Translating NIH Research to Racial and Ethnic Groups............180-181
Trans-NIH Primary Care Research.................................184-185
Tuberculosis Disparities Research...............................192-193
Tuberculosis Research...........................................174-175
Update on Diabetes and Sickle Cell..............................188-190
``Valley of Death'' Commercializing NIH Research Results........194-196
Vulvodynia....................................................... 158
Department of Health and Human Services
AHRQ's Mission................................................... 227
Awareness about Infections....................................... 246
Development of the HHS Action Plan..............................201-202
Financial Incentives............................................246-247
FY 2009 Funded Activities Outlined in the action Plan............ 202
HAI Reduction Strategies........................................239-240
Healthcare Investments..........................................300-303
Healthcare Provider Liability...................................296-298
Healthcare-Associated Infection Prevention in a Reformed Health
System........................................................202-203
Healthcare-Associated Infections................................305-309
Infection Control Training in Curriculums.......................244-245
Infection Data Reporting Transparency............................ 296
Infection Prevention Education................................... 312
Infection Tool Kit............................................... 242
Infections......................................................242-244
Keystone Project................................................310-311
Malpractice.....................................................238-239
MRSA.......................................................227, 237-238
Nurse and Healthcare Worker Shortages and Operating Costs.......298-300
Opening Statements
Dr. Besser..................................................213-215
Dr. Clancy..................................................227-229
Dr. Hyzy....................................................283-285
Dr. Pronovost...............................................249-252
Dr. Wright..................................................200-203
Ms. Stricof.................................................270-274
Outreach Campaign...............................................240-242
Preventing Infections............................................ 228
Prevention Checklist.......................................236-237, 245
Technical Strategies............................................. 247
Transparency....................................................247-248
Written Statements
Dr. Besser..................................................216-225
Dr. Clancy..................................................230-234
Dr. Hyzy....................................................286-292
Dr. Pronovost...............................................253-265
Dr. Wright..................................................204-211
Ms. Stricof.................................................275-280
Secretary of Labor
Advocate for a Safe Work Environment............................333-334
Chairman's Opening Remarks......................................313-314
Children in the Workforce.......................................343-344
Creating Green Jobs.............................................. 361
Critical Positions..............................................353-354
Diacetyl........................................................361-362
Educational System Involvement..................................346-347
Enhanced Enforcement Program....................................360-361
Fraudulent Claims................................................ 354
H1-B and L Visa Fraud............................................ 340
Impact of Recovery Act Money on Programming...................... 338
Improper Benefit Payments........................................ 351
Increase in Funding for Enforcement.............................. 334
Increasing Training Opportunities in Healthcare-Related Fields..350-351
Industries with Potential for Investment and Growth.............. 347
International Labor Affairs Bureau..............................364-365
Job Corps and Green Jobs........................................367-368
Job Corps Funding Request........................................ 367
Job Opportunities...............................................351-352
Job Training Dollars............................................337-338
Jobs in Manufacturing...........................................335-337
Migrant and Seasonal Farm Workers................................ 363
New Ways of Addressing Old Problems.............................348-349
Office of Labor--Management Standards...........................362-363
Opportunities for Women in the Workforce........................341-343
Opportunities for Youth.........................................352-353
Pension Benefit Guaranty Corporation............................. 341
Protection of Health care Workers in the Event of a Pandemic Flu344-345
Public Transit Benefit at DOL...................................338-339
Ranking Member's Opening Remarks................................314-316
Reducing Unemployment Disparities...............................334-335
Returning Veterans..............................................354-360
Secretary's Opening Statement...................................317-320
Secretary's Written Statement...................................321-331
Senior Community Service Employment Program...................... 340
State Aid.......................................................365-366
Telework and Telecommuting......................................363-364
Wages for Job Corps Instructors.................................345-346
WIA Reauthorization........................................339, 347-348
Secretary of Health and Human Services
Abstinence Only Programs........................................417-418
AIDS Funding and Minority Health Disparities....................406-408
Alabama Medicaid................................................. 459
Area Wage Index.................................................. 460
Assisting Refugees to Achieve Self Sufficiency..................427-428
Bioterrorism Funding............................................435-436
Cancer Research.................................................453-455
CDC HIV Prevention.........................................416, 436-437
Chronic Disease.................................................429-430
Chronic Disease Prevention Programs.............................416-417
Chronic Underfunding of the U.S. refugee resettlement Program...423-424
Collaboration in Medical Research................................ 453
Community-Based Prevention......................................430-432
Comparative Effectiveness Research..............................386-387
Comprehensive Sex Education Funding.............................. 440
Crowd Out of Private Health Insurance...........................387-388
Drug Resistant Tuberculosis.....................................433-434
Early Childhood and Health Care.................................389-390
Early Education; Mental Health Services.........................412-413
Emergency Housing Assistance....................................424-425
Ending Violence Against Abortion Providers and Health Care Refor400-402
Financing Health Care Reform...............................399-400, 411
Food Safety.....................................................409-140
Head Start....................................................... 434
Health Care for Children........................................402-403
Health Care Reform and HHS Budget Proposals.....................385-386
Health Care Reform and Oversight................................403-404
Health Care Reform and Private Insurance Options................408-409
Health Disparities.....................................392-393, 450-451
Health Disparities, Single-Payer System and Sex Education.......394-396
Health IT Systems...............................................448-450
Health Reform and Hidden Costs of Private Insurers..............440-442
Healthcare Reform................................................ 458
Healthcare Reform, H1N1 Flu Funding and Project Bioshield.......390-391
Healthcare System...............................................451-452
HIV/AIDS Funding for the CDC....................................446-447
HIV/AIDS, Health Disparities..................................... 411
Influenza Antiviral Treatment vs. Prophylaxis...................432-433
Institute of Medicine Report on the Critical Role of Title X
Funding........................................................ 447
Integration and Support to Professional Refugees................426-427
Integration of Services.........................................398-399
Mandatory Insurance.............................................393-394
Medical Advances and Comparative Effectiveness Research.........345-457
Microbides to Prevent HIV/AIDS..................................420-422
NIH Funding.....................................................391-392
NIH Funding and Health Care Reform..............................396-398
Office of Refugee Resettlement: U.S. Domestic Refugee
Resettlement Program and the Economic Crisis.........422-423, 437-439
Oversight and Medicare Reimbursement Disparities................413-415
Pandemic Influenza............................................... 452
Participation of Minorities in Accessing ARRA Funds.............443-446
Personalized Medicine...........................................455-456
Psycho-Social Needs of Refugees and Other Vulnerable Populations. 427
Public Health Workforce.........................................418-420
Recovery Act Funding: Minority Outreach, Mental Health Services.. 412
Refugee Women...................................................425-426
Ryan White HIV/AIDS Program...................................... 416
Secretary's Oral Statement......................................373-375
Secretary's Written Statement...................................376-383
Single-Payer System.............................................388-389
State and Community Involvement.................................. 410
Status of HIV Travel Ban........................................442-443
Stress Reduction................................................405-406
Substance Abuse Testing.......................................... 422
Tuberculosis..................................................... 448
Unplanned Pregnancies...........................................404-405
Utilizing Remaining ARRA Funds for Prevention.................... 446
Secretary of Education
Access to ACG/SMART.............................................. 506
Accountability for use of Recovery Funds........................486-487
Addressing the Nation's Dropout Program....................467, 489-490
After-School Programs and Lengthening the School Day............. 480
American Recovery and Reinvestment Act..........................465-466
ARRA Funds and HBCUs............................................492-493
ARRA Student Aid Funding by state................................ 493
Asian American and Native American Pacific Islander-Serving
Institution Program (AANAPISI)................................. 504
Budget Proposals Savings Offsets................................470-471
Bullying........................................................496-497
Chairman's Opening remarks....................................... 461
Charter Schools--Promoting Accountability and High Standards..... 497
Cheyenne Reservation in Montana.................................482-483
College Access and Completion Budget Proposals................... 470
College Completion Rates........................................495-496
Comprehensive Approach to family Literacy........................ 480
Department Programs Helping Veterans Transition to College......499-500
Early Learning Challenge Fund..............................469-470, 480
Educating the Nation's Workforce................................463-464
Education--A Civil Rights Issue.................................. 489
Education Funding Disparities.................................... 487
Education Technology Funding..................................... 484
Education, Job Training and Retraining........................... 464
Encouraging States to Engage with HBCUs.......................... 493
Engaging HBCUs in Teacher Education, School Reform, and Teach for
America........................................................ 494
English Language Acquisition Program Evaluations................. 501
Equalizing Aspect of Education..................................488-489
Equity........................................................... 503
ESEA Title I Decrease Proposed..................................462-463
ESEA, Title I and IDEA Stimulus Funding.......................... 469
Even Start Evaluations........................................... 479
Even Start Program--family Literacy Services..................... 479
Expansion of Preschool Programs.................................. 469
Funding Sources to Extend learning Opportunities................480-481
FY 2010 Education Budget Priorities.............................. 465
FY 2010 Education Budget Request................................. 467
HBCUs and Direct Lending......................................... 496
Historically Black Colleges and Universities....................491-492
Impact of Requirements on Some Leas and Schools.................. 477
Improving STEM Education........................................504-505
Improving Teacher Quality and Low-Performing Schools............. 467
Increasing Graduation Rates.....................................478-479
Long Term Plan to meet Federal Financial Obligations under IDEA.. 506
Minority Dropout Rates........................................... 489
National Education Standards and Goals........................... 485
National Teacher Recruitment Campaign............................ 468
Native American Students......................................... 486
NCLB Goals, Accountability and Flexibility......................477-478
NCLB Requirements for Special Needs Students..................... 477
Policy Commitments Under ARRA.................................... 466
Proposal to Make Pell Grants Mandatory........................... 463
Proposed Change to Mandatory Pell Grant.......................... 470
Proposed Education Budget Initiatives............................ 462
Proposed Even Start Elimination and Family Literacy.............. 483
Race to the Top.................................................503-504
Recovery Act and IDEA Funds...................................... 505
Recovery Act Funds and Budget Stabilization.....................461-462
Resources for Low-Performing Schools............................. 468
Rural Education Caucus..........................................481-482
Rural Education Concerns......................................... 481
Safe and Drug-Free Schools and Communities State Grants484-485, 502-503
School Reforms in Extending School Day and Year.................466-467
Secretary's Opening Statement...................................465-471
Secretary's Written Statement...................................472-475
State Budget Deficits and Accountability......................... 486
Statutory Provisions Promoting Accountability and High Standards. 498
Striving Readers Program...............................468-469, 479-480
Support for Latino Students.....................................500-501
Tax Remedies vs. Program Proliferation........................... 489
Teacher Incentive Fund Changes................................... 468
Three-Part Accountability and Technical Assistance Model for
Charter School Programs.......................................498-499
Timing of Proposed Initiatives and Economic turmoil.............. 462
Title I Grants to Local Educational Agencies..................... 491
Transition to Teaching Program and HBCU's.......................494-495
Tribal Colleges.................................................. 483
Trio and Gear Up Programs........................................ 483
Trio Programs and Postsecondary Success.......................... 482
U.S. 1st in World College graduates by 2020...................... 465
Unemployment in the Chairman's District.......................... 461
White House Initiative on HBCUs.................................493-494
Young Readers Programs........................................... 469