    [Senate Hearing 111-850]
    [From the U.S. Government Publishing Office]

                                                            S. Hrg. 111-850

                                                            Senate Hearings

                                     Before the Committee on Appropriations

    _______________________________________________________________________

                                                      Departments of Labor,

                                                 Health and Human Services,

                                                 and Education, and Related

                                                    Agencies Appropriations

                                                           Fiscal Year 2010

                                              111th Congress, First Session

                                                                  H.R. 3293

            DEPARTMENT OF EDUCATION
            DEPARTMENT OF HEALTH AND HUMAN SERVICES
            DEPARTMENT OF LABOR
            NONDEPARTMENTAL WITNESSES

                                                           S. Hrg. 111-850

      DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES, AND EDUCATION, AND
              RELATED AGENCIES APPROPRIATIONS FOR FISCAL YEAR 2010

    =======================================================================

                                    HEARINGS

                                    before a

                              SUBCOMMITTEE OF THE

                COMMITTEE ON APPROPRIATIONS UNITED STATES SENATE

                         ONE HUNDRED ELEVENTH CONGRESS

                                 FIRST SESSION

                                       on

                                   H.R. 3293

     AN ACT MAKING APPROPRIATIONS FOR THE DEPARTMENTS OF LABOR, HEALTH AND
    HUMAN SERVICES, AND EDUCATION, AND RELATED AGENCIES FOR THE FISCAL YEAR
               ENDING SEPTEMBER 30, 2010, AND FOR OTHER PURPOSES

                                   __________

                            Department of Education
                    Department of Health and Human Services
                              Department of Labor
                           Nondepartmental Witnesses

                                   __________

             Printed for the use of the Committee on Appropriations

          Available via the World Wide Web: http://www.gpo.gov/fdsys

                                   __________

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                          COMMITTEE ON APPROPRIATIONS

                       DANIEL K. INOUYE, Hawaii, Chairman
    ROBERT C. BYRD, West Virginia        THAD COCHRAN, Mississippi
    PATRICK J. LEAHY, Vermont            CHRISTOPHER S. BOND, Missouri
    TOM HARKIN, Iowa                     MITCH McCONNELL, Kentucky
    BARBARA A. MIKULSKI, Maryland        RICHARD C. SHELBY, Alabama
    HERB KOHL, Wisconsin                 JUDD GREGG, New Hampshire
    PATTY MURRAY, Washington             ROBERT F. BENNETT, Utah
    BYRON L. DORGAN, North Dakota        KAY BAILEY HUTCHISON, Texas
    DIANNE FEINSTEIN, California         SAM BROWNBACK, Kansas
    RICHARD J. DURBIN, Illinois          LAMAR ALEXANDER, Tennessee
    TIM JOHNSON, South Dakota            SUSAN COLLINS, Maine
    MARY L. LANDRIEU, Louisiana          GEORGE V. VOINOVICH, Ohio
    JACK REED, Rhode Island              LISA MURKOWSKI, Alaska
    FRANK R. LAUTENBERG, New Jersey
    BEN NELSON, Nebraska
    MARK PRYOR, Arkansas
    JON TESTER, Montana
    ARLEN SPECTER, Pennsylvania
                        Charles J. Houy, Staff Director
                      Bruce Evans, Minority Staff Director
                                     ------

     Subcommittee on Departments of Labor, Health and Human Services, and
                        Education, and Related Agencies

                           TOM HARKIN, Iowa, Chairman
    DANIEL K. INOUYE, Hawaii             THAD COCHRAN, Mississippi
    HERB KOHL, Wisconsin                 JUDD GREGG, New Hampshire
    PATTY MURRAY, Washington             KAY BAILEY HUTCHISON, Texas
    MARY L. LANDRIEU, Louisiana          RICHARD C. SHELBY, Alabama
    RICHARD J. DURBIN, Illinois          LAMAR ALEXANDER, Tennessee
    JACK REED, Rhode Island
    MARK PRYOR, Arkansas
    ARLEN SPECTER, Pennsylvania

                               Professional Staff

                                  Ellen Murray
                                  Erik Fatemi
                                  Mark Laisch
                                Adrienne Hallett
                                 Lisa Bernhardt
                           Bettilou Taylor (Minority)
                        Sudip Shrikant Parikh (Minority)
                            Dale Cabaniss (Minority)

                             Administrative Support

                                  Teri Curtin
                             Jeff Kratz (Minority)

                                C O N T E N T S

                                  ----------

                            Wednesday, May 13, 2009

                                                                       Page

    Department of Labor: Office of the Secretary.....................     1

                             Thursday, May 21, 2009

    Department of Health and Human Services: National Institutes of
      Health.........................................................    63

                            Wednesday, June 3, 2009

    Department of Education: Office of the Secretary.................   163

                             Tuesday, June 9, 2009

    Department of Health and Human Services: Office of the Secretary.   237
    Nondepartmental Witnesses........................................   279

      DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES, AND EDUCATION, AND
              RELATED AGENCIES APPROPRIATIONS FOR FISCAL YEAR 2010

                                  ----------

                            WEDNESDAY, MAY 13, 2009

                                           U.S. Senate,
               Subcommittee of the Committee on Appropriations,
                                                        Washington, DC.
        The subcommittee met at 9:47 a.m., in room SD-138, Dirksen
    Senate Office Building, Hon. Tom Harkin (chairman) presiding.
        Present: Senators Harkin, Murray, Pryor, and Cochran.

                              DEPARTMENT OF LABOR

                            Office of the Secretary

    STATEMENT OF HON. HILDA L. SOLIS, SECRETARY

                    opening statement of senator tom harkin

        Senator Harkin. Good morning. The Subcommittee on Labor,
    Health, Human Services, Education and related agencies will
    come to order. I'm very pleased to welcome Secretary Solis in
    her first appearance before this subcommittee. Welcome Madam
    Secretary, and again, congratulations on your appointment to
    this very important position.
        It's been less than 4 months since President Obama took the
    oath of office, and inherited our current economic crisis, the
    likes of which we haven't seen since the Great Depression. In
    January, our Nation was shedding more than 600,000 jobs a
    month, millions more working part time because they could not
    find full-time work. Businesses were slowing down. It was in
    this context that Secretary Solis began her tenure as our
    Nation's 25th Secretary of Labor.
        Madam Secretary, as you're well aware, the Department of
    Labor (DOL) carries out a critical mission that is particularly
    important in these challenging times. The Department must
    ensure that the Nation's public workforce development system is
    providing employers with access to a skilled workforce. We need
    to enforce our Nation's laws on establishing safe workplaces
    and work for economic security, but also in this time, worker
    retraining, job retraining for so many workers that have been
    displaced.
        I think we've paid too little attention to some of these
    priorities. Previous budget requests have routinely cut funding
    for job training and under-invested in Occupational Safety and
    Health Administration (OSHA) and the Mine Safety and Health
    Administration (MSHA) and the Employment Standards
    Administration (ESA). I am pleased to say that the fiscal year
    2010 budget request before this subcommittee is a very welcome
    change and appears to be consistent with my view of the
    important work supported by the Department of Labor.
        For the first time in 9 years, the budget request does not
    include a devastating cut in funding for the International
    Labor Affairs Bureau (ILAB). I want to thank you, Secretary
    Solis, for proposing a $91 million budget for ILAB, an increase
    of $5 million over the 2009 funding level.
        As I mentioned during your confirmation hearing, ILAB is a
    very important priority for me. I think it sends an important
    message around the world, the United States will help lead the
    fight against the worst forms of child labor.
        And this funding is particularly critical, as economic
    challenges around the world push back against the progress
    that's been made in recent years, in getting children out of
    dangerous workplaces and back into the classroom. As you know,
    this is the 10th anniversary of the adoption of ILO Convention
    182, and I'm hopeful that the Department of Labor, under your
    leadership, will commemorate this historic occasion. In fact, I
    was in Seattle with President Clinton when he--when we became a
    signatory to that, and then later traveled with President
    Clinton to Geneva when it was adopted by the ILO, in Geneva.
    That was 10 years ago. So I hope we at least do something to
    commemorate this 10th anniversary. For myself, I will be in
    Geneva on that day, so I won't be here to celebrate, but I hope
    that we have some commemoration of it here.
        I also want to thank you for your support of worker
    protection agencies, where the budget proposes to bring
    staffing levels back to those supported at the end of the
    Clinton administration. Enforcement staff levels are down by
    one-third at the Wage and Hour Division, and below the fiscal
    year 2001 level at OSHA.
        Many years have passed without issuing a single ergonomic
    citation, even though musculoskeletal disorders constitute one-
    third of all workplace injuries. It developed an enhanced
    enforcement program that was ``enhanced'' in name only, and
    record low workplace injury rates were highlighted, despite the
    first comprehensive analysis revealing an apparent under
    accounting of workplace injuries.
        Madam Secretary, I look forward to working with you to
    change the direction of the Department of Labor's worker
    protection agencies, to ensure they have sufficient resources
    and the right strategy for carrying out their important work.
        And again, I'd like to work with you to improve employment
    opportunities for individuals with disabilities. We've talked
    about that issue--another longstanding priority of mine. I
    appreciate your proposed $37 million budget for the Office of
    Disability Employment Policy (ODEP). That's an increase of $10
    million over the 2009 level.
        Data now being released by the Department's Bureau of Labor
    Statistics reveal that roughly 80 percent of individuals with
    disabilities are not in the labor force. This is really
    unacceptable, 19 years after the passage of the Americans With
    Disabilities Act. So we must improve this situation.
        And I look forward to working with you to ensure that ODEP
    can carry out its mission, and work effectively with other
    agencies in the Government to ensure that the policies of our
    government foster improved employment opportunities for
    individuals with disabilities.
        Madam Secretary, enacting the 2010 Labor appropriations
    bill will not be an easy task. There are many worthy health,
    education, and labor programs competing for a limited
    discretionary allocation. Some will suggest that the deficit is
    too big, so Congress should simply cut spending. Others will
    express concern about programs not increased enough or proposed
    for elimination, especially during tough times when we need to
    support our workers and our workforce.
        Again, I do have some questions I will ask about the
    proposal to eliminate funding for the Work Incentives Grant
    Program and tight funding request for Job Corps. However, I
    believe the budget proposal before us establishes the right
    priorities for our Nation and will move us towards safer
    workplaces and a better skilled workforce.
        Madam Secretary, again, welcome to the subcommittee. I look
    forward to your testimony on the budget request.
        And I would yield now to our distinguished ranking member,
    Senator Cochran.

                       statement of senator thad cochran

        Senator Cochran. Mr. Chairman, thank you very much.
        Welcome, Madam Secretary, to this first hearing of our
    committee, and with your serving as Secretary, we congratulate
    you on your assumption of these important responsibilities and
    we look forward to working with you to help make sure that we
    do approve the funding levels and the programs under the
    jurisdiction of the Department of Labor that are important to
    our Nation's workforce and to our Nation-at-large. It's a big
    undertaking--it's a big building over there, too, isn't it?
        Anyway, I remember when Elizabeth Dole, I think, was there.
    No, she was at HHS. Elizabeth Dole was there. Her husband, of
    course, tended to be quick-witted and sometimes he said things
    that he wished he had taken back. And he made some comment
    about how large the building was and how many people work here.
    And somebody said, ``About half of them.''
        He said, ``About half of them.'' Anyway, I shouldn't be
    trying to tell Bob joke--Bob Dole jokes. They don't work for
    me.
        But, we know that you've indicated that there will be $135
    million in this budget for a new Career Pathways program which,
    as I understand it, will take the place of the community-based
    job training activities of the Department. It will be
    interesting to hear what your thoughts are about how that would
    be a step forward.
        Also, there's some increases, as you point out, in
    programs--or as the chairman pointed out in his comments, and
    we'll--we'll look carefully at those too, but we appreciate
    your cooperation with our subcommittee and coming here to help
    us understand the budget request.
        Senator Harkin. Thank you very much, Senator Cochran.
        Secretary Solis, again, welcome. Your statement will be
    made a part of the record, in its entirety. We were advised we
    may have a vote around 10:30 a.m., but I don't know if that's
    still true or not, but we'll try to see if we can move ahead.
        So, please proceed as you so desire, Madam Secretary.

                    summary statement of hon. hilda l. solis

        Secretary Solis. Thank you very much, Chairman Harkin and
    Senator Cochran. It's good to be here before you. And also
    Senator Murray and the other subcommittee members, who I
    understand may be coming in and out today.
        I'm happy to be here today, before your subcommittee. I
    want to thank you for the invitation to testify and present you
    with the President's fiscal year 2010 budget, the request for
    the Department of Labor.
        And I'd like to just summarize my remarks and ask that my
    testimony also be entered into the record formally.
        And, just to begin with, I want to outline what our fiscal
    year 2010 overall three major priorities are.
        And they are, as you said, Senator Harkin, to begin with,
    worker protection. We're beginning to restore the capacity of
    the programs that protect workers' health, safety, pay, and
    benefits.
        Second, a green recovery. What do I mean? I mean
    implementing new and innovative ways to promote economic
    recovery by working toward energy independence, and increasing
    competitiveness of our Nation's workforce.
        And third, accountability and transparency. We will ensure
    that all of our programs are carried out in way that is
    accountable, transparent to our stakeholders and to the public.
        And in all these efforts, I'm committed to fostering
    diversity, to ensuring that our programs are accessible to
    previously underserved populations, including those in rural
    communities. And I'm particularly proud that the fiscal year
    2010 budget begins to restore programs protections for workers.
    The fiscal year 2010 budget, the Department of Labor is
    requesting $1.7 billion for worker protection programs.
        As you said earlier, Senator Harkin, it's about a 10
    percent increase for worker protection, which is above the
    fiscal year 2009 level. We're adding 878 enforcement positions.
    The budget will return our worker protection efforts to a level
    not seen since 2001. And we're increasing our capacity--so
    dramatically in a single year--which I know is unprecedented.
    But we're ready with an aggressive comprehensive hiring plan
    that will be implemented as soon as the fiscal year 2010
    funding is available.
        I want to highlight three agencies where the increases are
    most substantial due to the erosion in enforcement capacity
    over the last 8 years.
        The additional resources provided for the Wage and Hour
    Division will allow the Agency to do the following: improve
    compliance in low-wage industries that employ vulnerable
    workers; increase its focus on reducing repeat violations; and
    strategically conduct compliant investigations.
        Second, the increase for OSHA will allow us to add 213 new
    staff, such as enforcement personnel, standard writers, and
    bilingual staff to address the changing demographics in the
    workplace, as well as increase funding for our State program
    grants.
        Third, to promote equal opportunity in Federal contracting,
    through expansion of the Office of Contract Compliance
    Programs. The number compliance officers there will go to 213
    FTE.
        The increases in our enforcement programs will require,
    also, legal services and support for the Office of the
    Solicitor, where we also request an increase.
        And I'm hopeful that the Congress will meet our worker
    protection program request, to allow the Department to meet its
    responsibility to all American workers.
        And as you are aware, DOL is currently using Recovery Act
    funds for a range of activities that provide transitional
    benefits, job training, and placement assistance to unemployed
    workers. Our fiscal year 2010 request supplements Recovery Act
    funding through targeted investments in employment and training
    programs.
        For dislocated workers, a $71 million increase will go to
    the National Reserve Account, which will help to fund National
    Emergency Grants, allowing for targeted response to large-scale
    worker dislocations, as we're experiencing now.
        Through a new Career Pathways Innovation Fund, we will fund
    grants to community colleges and other educational institutions
    to help individuals advance up career ladders in growth sectors
    like healthcare and IT.
        For green jobs, the budget requests $50 million for
    enhanced apprenticeship and competitive grants. We'll also
    pursue strategies to equip all our training programs to provide
    training in the new green economy. And we've included funding,
    also, for the Bureau of Labor Statistics (BLS), to produce
    valuable information to help us define green jobs.
        Within our request for pilots and demonstrations, the
    budget also includes an 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 Youth
    Build Program, to train low-income at-risk youth.
        And the request for the Veterans Employment and Training
    Services contains strategic investments that will allow the
    Agency to reach out to homeless veterans, including those who
    are women; make employment workshops available to families of
    veterans and transitioning servicemembers; and to restructure
    our existing training grants to focus on green jobs.
        These innovative strategies will supplement our core
    workforce security programs that are extremely sensitive to
    economic conditions, including 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 our
    State programs.
        In addition to providing States with the resources to cover
    increased workloads, our approach includes increased funding
    for reemployment and eligibility assessment, to help claimants
    return to work as soon as possible.
        I know that you share the belief that I do, that spending
    tax dollars wisely is very important to our mission and our
    core goals of putting American workers back to work. A number
    of our budget proposals support the goals of accountability and
    I'd like to name them.
        A new $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 in
    job training program evaluations, which will help us understand
    which approaches are effective and will help inform the
    direction of future programs. And an additional $5 million
    program evaluation initiative, that will help the Department
    examine all of our programs, not just in employment and
    training.
        And I'd like to say just a few words about some other
    programs that I know you're interested in. First, the budget
    provides an increase of $10 million for the Office of
    Disability Employment Policy. The increase will allow us to
    build on the lessons we learned through the Work Incentive
    Grant demonstration, and it will allow us to promote
    opportunities for individuals with disabilities, particularly
    young people in employment apprenticeship program, pre-
    apprenticeship programs and community service activities.
        And second, the budget request, as you stated, Mr.
    Chairman, will provide an increase of $5.3 million for the
    Bureau of Labor International Affairs, ILAB. With these funds,
    ILAB will be able to step up monitoring and oversight of labor
    rights, through closer monitoring and reporting on labor
    conditions worldwide, particularly with our trading partners,
    while also maintaining ILAB's Child Labor and Worker Rights
    grant activities.

                               prepared statement

        In conclusion, I'm committed to ensuring that these new
    efforts, along with all the programs supported by the
    Department's fiscal year 2010 budget, will demonstrate that we
    are putting our workers first, not just our workers, but their
    families. I ask for your support on this request and would be
    happy to respond to any of your questions.
        [The statement follows:]
                      Prepared Statement of Hilda L. Solis
        Chairman Harkin, Ranking Member Cochran, and members of the
    subcommittee, thank you for the invitation to testify today. I
    appreciate the opportunity to discuss the President's fiscal year 2010
    budget request for the Department of Labor (DOL).
        The total request for the Department in fiscal year 2010 is $104.5
    billion and 17,477 Full-Time Equivalent (FTE) employees, of which $15.9
    billion is before the subcommittee. Of that amount, $13.3 billion is
    requested for discretionary budget authority. Our budget request will
    build on the $4.8 billion in discretionary and $33.5 billion in
    mandatory resources included for the Department in the American
    Recovery and Reinvestment Act (Recovery Act).
        It is no secret that the economy is struggling. Investing in our
    Nation's workforce and creating a positive environment for new jobs is
    a critical component of the President's efforts to restart our economy.
    For its part, the Department of Labor is deploying its Recovery Act
    resources to help ease the burden of unemployment and put people back
    to work by:
      --Providing more training and employment opportunities for seniors,
            unemployed adults, and dislocated workers;
      --Providing Summer Jobs and full-year opportunities for youth;
      --Spurring new Green Jobs training investments, to prepare workers to
            succeed in the new green economy;
      --Enhancing and expanding the Unemployment Compensation and Trade
            Adjustment Assistance programs;
      --Launching a new program that informs workers and their families of
            their rights under the Recovery Act to COBRA premium
            assistance; and
      --Initiating additional worker protections to ensure that economic
            activity spurred by the Recovery Act occurs in workplaces that
            are safe, healthful, and respect workers' rights.
        The resources requested in our fiscal year 2010 budget will build
    on and leverage the efforts begun this year with the Recovery Act. The
    Department's fiscal year 2010 budget will promote continued economic
    recovery and strengthen the health, safety, and competitiveness of our
    Nation's diverse workforce.
                          fiscal year 2010 priorities
        While building on the efforts begun under the Recovery Act, the
    Department's fiscal year 2010 budget features three overall priorities:
    beginning to restore the capacity of our programs that protect workers'
    safety and health, pay, and benefits; launching new and innovative ways
    to promote economic recovery and the competitiveness of our Nation's
    workers; and ensuring that our programs are carried out in a way that
    is accountable and transparent to the public and our stakeholders.
                      restoring worker protection programs
        The 2010 budget includes $1.7 billion in discretionary funds and
    10,182 FTE for DOL's worker protection activities. This funding level
    is $150 million (10 percent) and 878 FTE above the fiscal year 2009
    enacted level, and returns the worker protection programs to their
    fiscal year 2001 staffing levels. The request will restore capacity in
    our worker protection programs, which have languished for years. The
    Department has developed an aggressive, comprehensive hiring plan for
    its worker protection agencies, which it will deploy as soon as the
    fiscal year 2010 appropriation is available. Our plan places a special
    emphasis on hiring multilingual inspectors and investigators to allow
    the worker protection personnel to match the languages used in the
    workplace.
    Employment Standards Administration
        The Department's Employment Standards Administration (ESA)
    administers and enforces laws that protect the rights and welfare of
    American workers. The fiscal year 2010 budget request for
    administrative expenses for ESA is $503 million and 4,538 FTE. This
    represents an increase of $63 million (14 percent) and 493 FTE above
    the fiscal year 2009 enacted level.
    Wage and Hour Division
        The Wage and Hour Division is responsible for the administration
    and enforcement of a wide range of worker protection laws, including
    the Fair Labor Standards Act, Family and Medical Leave Act, Migrant and
    Seasonal Agricultural Worker Protection Act, worker protections
    provided in several temporary nonimmigrant visa programs, and
    prevailing wage requirements of the Davis-Bacon Act and the Service
    Contract Act. The Wage and Hour Division protects more than 135 million
    workers in more than 7.3 million establishments.
        The fiscal year 2010 budget requests $227.7 million and 1,571 FTE
    for the Wage and Hour Division, an increase of $35 million and 288 FTE
    from the fiscal year 2009 enacted level. It includes resources to help
    revive its customer service focus by supporting improved complaint
    intake and more in-depth complaint investigation processes. In fiscal
    year 2010, the Wage and Hour Division will hire additional
    investigators to:
      --Strengthen enforcement resources on behalf of vulnerable workers;
      --Verify future compliance of prior violators; and
      --Conduct high-quality, responsive complaint investigations
            strategically, to increase protections for the greatest number
            of workers.
        The fiscal year 2010 budget request for the Wage and Hour Division
    excludes $45 million in estimated fee revenue from DOL's portion of the
    H-1B and L visa fraud prevention fee authorized by the 2004 H-1B Visa
    Reform Act. Because of the statutory limits on the use of these funds,
    DOL has been unable to spend all of the fees, and each year carries
    unspent balances. The fiscal year 2010 budget proposes to cancel $30
    million of these balances as an offset to new discretionary spending.
    The administration is also proposing legislation, through the
    Department of Homeland Security, to amend the Immigration and
    Nationality Act to expand the permissible uses for the Department of
    Labor to use the H-1B and L fraud fees to carry out expanded
    enforcement activities under the H1B and L, as well as provide a stable
    source of funding for enforcement of the H-2B program.
    Office of Federal Contract Compliance Programs
        The fiscal year 2010 budget request for the Office of Federal
    Contract Compliance Programs (OFCCP) totals $109.5 million and 798 FTE,
    an increase of $27 million (33 percent) and 213 FTE from the fiscal
    year 2009 level. OFCCP is responsible for ensuring equal employment
    opportunity and nondiscrimination in employment for businesses
    contracting with the Federal Government. In fiscal year 2010, OFCCP
    will carry out this mandate by conducting compliance evaluations to
    identify instances of systemic discrimination in the workplace, with a
    special focus on construction reviews and on-site evaluations related
    to veterans and individuals with disabilities. The fiscal year 2010
    request includes $2 million for a new case management system to replace
    the agency's existing case management system (the OFCCP Information
    System), which was developed over 20 years ago and is inadequate to
    meet today's enforcement needs. The new system will improve the
    monitoring of noncompliant contractors and improve the effectiveness of
    OFCCP's enforcement activities.
    Office of Workers' Compensation Programs
        The fiscal year 2010 discretionary budget request for
    administration of the Office of Workers' Compensation Programs (OWCP)
    totals $108.5 million and 890 FTE to support the Federal Employees'
    Compensation Act (FECA) ($95.3 million) and the Longshore and Harbor
    Workers' Compensation program ($13.2 million).
        The OWCP budget also includes mandatory funding totaling $51.2
    million and 305 FTE to administer Part B of the Energy Employees
    Occupational Illness Compensation Program Act (EEOICPA), and $60
    million and 293 FTE for Part E of the Act. EEOICPA provides
    compensation and medical benefits to employees or survivors of
    employees of the Department of Energy (DOE) and certain of its
    contractors and subcontractors, who suffer from a radiation-related
    cancer, beryllium-related disease, chronic silicosis, or other covered
    illness as a result of work at covered DOE or DOE contractor
    facilities.
        Lastly, OWCP's fiscal year 2010 budget includes $37.5 million in
    mandatory funding and 195 FTE for its administration of Parts B and C
    of the Black Lung Benefits Act, and $58.1 million and 127 FTE in FECA
    Fair Share administrative funding. The request for FECA Fair Share
    includes an increase of $4.95 million to upgrade technology, improve
    customer service, and increase productivity.
    Office of Labor-Management Standards
        The fiscal year 2010 budget request for the Office of Labor-
    Management Standards (OLMS) totals $40.6 million and 266 FTE. This is a
    net reduction of $4.38 million and 31 FTE from the fiscal year 2009
    level. OLMS administers the Labor-Management Reporting and Disclosure
    Act (LMRDA), which establishes safeguards for union democracy and union
    financial integrity and requires public disclosure reporting by unions,
    union officers, employees of unions, labor relations consultants,
    employers, and surety companies. OLMS also administers the Department's
    responsibilities under Federal transit law by ensuring that fair and
    equitable arrangements protecting mass transit employees are in place
    before the release of Federal transit grant funds.
        The resources requested in fiscal year 2010 will allow OLMS to
    continue to accomplish its core mission. The reduction in FTE will
    occur through the transfer of staff to other ESA programs and
    attrition. The budget would shift those resources to other worker
    protection agencies that have faced increased workload in the face of
    diminished resources.
    Employee Benefits Security Administration
        The Employee Benefits Security Administration (EBSA) protects the
    integrity of pensions, health plans, and other employee benefits for
    more than 150 million workers. The fiscal year 2010 budget request for
    EBSA is $156.1 million and 910 FTE, an increase of $13 million (9
    percent) and 75 FTE compared to the fiscal year 2009 level. The
    requested resources will help rebuild the foundation of EBSA's
    enforcement efforts, allowing an additional 600 civil and criminal
    investigations and increasing indictments by an estimated 6 percent.
    Occupational Safety and Health Administration
        The fiscal year 2010 budget request for the Occupational Safety and
    Health Administration (OSHA) is $563.6 million and 2,360 FTE. The
    budget requests an additional $50.6 million and 213 FTE, and proposes
    program increases to restore OSHA's capacity to enforce statutory
    protections, provide technical support, promulgate safety and health
    standards, and strengthen safety and health statistics. The fiscal year
    2010 request supports an additional:
      --130 safety and health inspectors (a 10 percent increase from fiscal
            year 2009);
      --25 whistleblower investigators (a 33 percent increase);
      --$13.84 million for State Program grants (a 15 percent increase);
      --13 FTE to strengthen OSHA's capacity to quickly respond to the
            sudden emergence of safety and health hazards, such as a
            pandemic influenza; and
      --20 FTE to restore OSHA's rulemaking capabilities, allowing the
            Agency to simultaneously address multiple complex longstanding
            and emerging regulatory issues.
        These additional resources will restore OSHA's enforcement presence
    in the Nation's workplace, support National and Local Emphasis
    Programs, and allow the agency to hire multilingual investigators to
    address language barriers in enforcement.
    Mine Safety and Health Administration
        The fiscal year 2010 budget request for the Mine Safety and Health
    Administration (MSHA) is $353.7 million and 2,376 FTE. The request will
    allow MSHA to continue implementing the historic Mine Improvement and
    New Emergency Response (MINER) Act, the most sweeping mine safety
    legislation in 30 years.
        The fiscal year 2010 budget includes an increase of $1.3 million
    specifically targeted for 15 additional Metal and Nonmetal FTE to
    address the projected 12 percent increase in workload in the aggregates
    mining sector. The budget will ensure a 100 percent completion rate for
    all mandatory safety and health inspections; support MSHA's enhanced
    enforcement initiatives, which target patterns of violation, flagrant
    violators, and scofflaws; and continue infrastructure improvements at
    the National Mine Health and Safety Academy. The request also allows
    MSHA to continue its work to enhance mine rescue and emergency
    operations.
    Office of the Solicitor
        The fiscal year 2010 budget includes $125.2 million and 679 FTE for
    the Office of the Solicitor (SOL). This amount includes $117.4 million
    in discretionary resources and $7.8 million in mandatory funding. The
    Solicitor's Office provides the legal services that support the
    Department, particularly the Department's enforcement programs. The
    fiscal year 2010 budget includes an increase of $14.8 million that will
    support an additional 82 FTE to provide expanded legal support for DOL
    client agencies, and provide $5.3 million for information technology
    and legal support infrastructure. The additional staff will better
    enable SOL to provide increased enforcement litigation, more timely
    legal opinions, and legal support for rulemaking. The $5.3 million
    request for infrastructure will increase SOL's litigation efficiency
    and improve its case management and reporting system.
    Pension Benefit Guaranty Corporation
        For administrative expenses of the Pension Benefit Guaranty
    Corporation (PBGC), the fiscal year 2010 budget requests $464.1 million
    and 931 FTE, an increase of $19.3 million over the fiscal year 2009
    level. In fiscal year 2010, PBGC will strive to prevent unnecessary and
    avoidable terminations of underfunded pension plans, to mitigate the
    risk of losses to the insurance program, and to enhance recoveries in
    bankruptcy for the benefit of plan participants and the insurance
    funds. The request includes an additional $15 million to help PBGC
    respond to the threat posed by the struggling economy to defined
    benefit pension plans. These funds will support actuarial and financial
    advisory services to better understand the exposure and risk faced by
    the pension insurance program. In addition, $500,000 and three FTE are
    requested to increase the capacity of the Office of Inspector General
    to investigate PBGC's benefit payment, asset management, and
    contracting operations.
        The budget also includes a change to the appropriations language
    that ``triggers'' the availability of additional administrative funds
    if there are unanticipated pension plan termination-related expenses.
    Because of concerns that a large plan failure late in the fiscal year
    would trigger additional funds that could not be fully obligated within
    the fiscal year, the budget proposes to make these triggered funds
    available for 2 years.
                    innovative workforce training strategies
        The fiscal year 2010 budget request for the Department's Employment
    and Training Administration (ETA) is $8.7 billion in discretionary
    funds and 812 FTE, not including the 131 FTE associated with the
    foreign labor certification application fees.
        We are grateful to the Congress for providing funding for the
    employment and training programs in the Recovery Act. This funding
    provides the basis of an aggressive plan to put Americans back to work.
    Our fiscal year 2010 budget request will supplement Recovery Act
    funding with the targeted investments highlighted in this section. I am
    particularly excited about the use of innovative strategies and
    programs designed to increase the skills and competitiveness of the
    American workforce, including segments of the population that have been
    underserved in the past.
    Dislocated Workers
        The budget requests an increase of $71.1 million in the Dislocated
    Worker National Reserve to fund National Emergency Grants. This will
    enable ETA to provide additional, targeted resources to aid in the re-
    employment of dislocated workers, as current projections indicate that
    there will continue to be high levels of unemployment into fiscal year
    2010.
        The economy, along with a major expansion of eligibility and
    benefits enacted as part of the Recovery Act, is also the primary
    factor in the request for an increase of $860 million for the Trade
    Adjustment Assistance program, which will support training and income
    support for trade-impacted workers. States that assist workers who lose
    jobs will also receive $3.2 billion for the administration of
    unemployment insurance based on estimates of claims workload for the
    fiscal year.
    Career Pathways Innovation Fund
        The fiscal year 2010 budget requests $135 million for the Career
    Pathways Innovation Fund, which is a $10 million increase over the
    amount awarded in fiscal year 2009 through Community-Based Job Training
    Grants. Competitive grants provided by the new fund will continue the
    support for community colleges provided by Community-Based Job Training
    Grants, but will focus on career pathway programs at community
    colleges. These programs help individuals of varying skill levels enter
    and pursue rewarding careers in high-demand and emerging industries.
        Career pathway programs are clear sequences of coursework and
    credentials, each leading to a better job in a particular field, such
    as healthcare, law enforcement, and clean energy. These programs have
    multiple entry and exit points and often include links to services,
    such as basic adult education and English-as-a-Second Language classes,
    which make them accessible to individuals who are not yet prepared to
    enroll in college courses. Career pathways are a relatively new
    strategy for community colleges, but several existing programs have
    shown promising outcomes.
        The Department will work with the Department of Education as it
    develops and implements this new initiative, especially to gain insight
    into curriculum development, the importance of credit transferability,
    and linkages between community colleges and K-12 education.
    Green Jobs
        The budget requests $50 million for a Green Jobs Innovation Fund,
    which will complement the competitive grant awards made through the
    $500 million appropriation included for high growth and emerging
    industry sectors under the Recovery Act. The Department is considering
    several targeted strategies for these funds, including: (1) enhanced
    apprenticeship opportunities in green industry sectors and occupations;
    (2) competitive grants for green career pathways, focusing on
    developing educational opportunities in green industries; and (3)
    incentives for innovative partnerships that connect community-based
    organizations in underserved communities with the workforce investment
    system to promote career advancement in green industry sectors.
    YouthBuild
        The fiscal year 2010 budget includes $114 million, an increase of
    $44 million, or 64 percent, over the fiscal year 2009 enacted level for
    YouthBuild to provide competitive grants to local organizations for the
    education and training of approximately 7,100 disadvantaged youth ages
    16-24. Under these grants, youth will participate in classroom training
    and learn construction skills by helping to build affordable housing.
    In fiscal year 2010, the Department will continue the ``green''
    transition of YouthBuild by encouraging connections with other Federal
    agencies involved in creating green jobs, such as the Department of
    Housing and Urban Development (HUD) and the Department of Energy in
    order to leverage resources and new ``green'' opportunities for
    YouthBuild participants.
    Transitional Jobs
        The fiscal year 2010 budget proposes $50 million to demonstrate and
    evaluate transitional job program models, which combine short-term
    subsidized or supported employment with case management services to
    help individuals with significant employment barriers obtain the skills
    needed to secure unsubsidized jobs. The initiative will target
    noncustodial parents to strengthen their workforce skills and
    experience, and help the children who rely on them for support. The
    Department will carry out this demonstration collaboratively with other
    Federal agencies, such as the Departments of Health and Human Services
    and Justice. We will work with partner agencies to develop and
    implement a rigorous evaluation strategy for this demonstration.
    Reintegration of Ex-offenders
        The fiscal year 2010 budget requests $115 million, an increase of
    $6.5 million over the fiscal year 2009 enacted level, for a program
    that brings together projects for adult and youth offenders. A portion
    of the funding will be used to support ex-offender programs under the
    Second Chance Act, and provide job training, mentoring, and
    transitional services to ex-offenders. The funding will also support
    grants to target juvenile and young adult offenders, and youth highly
    at risk of involvement in crime and violence.
    Strengthening Unemployment Insurance Integrity and Promoting Re-
            employment
        The economic downturn has placed great stress on the Unemployment
    Insurance (UI) system, which finances the unemployment compensation
    program. In addition to financing the administration of State
    workloads, the administration is committed to protecting the financial
    integrity of the UI system, and to helping unemployed workers return to
    work as promptly as possible. Our approach includes:
      --A total of $50 million in discretionary funding, an increase of $10
            million over the fiscal year 2009 enacted level, to expand
            Reemployment and Eligibility Assessments, which include in-
            person interviews at One-Stop Career Centers with UI
            beneficiaries to discuss their need for re-employment services
            and their continuing eligibility for benefits. This initiative
            has helped UI beneficiaries find jobs faster and reduced
            payments to ineligible individuals.
      --A package of legislative changes that would prevent, identify, and
            collect UI overpayments and delinquent employer taxes. We
            estimate that these legislative proposals would reduce
            overpayments by $3.9 billion and employer tax evasion by $300
            million over 10 years.
        In addition, the administration will seek reform of the UI
    program's permanent Extended Benefit (EB) feature to improve its
    efficiency as an automatic economic stabilizer and streamline
    administration. We urge the Congress to act on these important
    proposals to strengthen the financial integrity of the UI system and
    help unemployed workers return to work.
    Senior Community Service Employment Program
        The fiscal year 2010 budget proposes $575 million for the Senior
    Community Service Employment Program (SCSEP), which will enroll some
    90,000 low-income seniors in part-time, minimum wage community service
    jobs. The request includes an additional $3.5 million over the fiscal
    year 2009 enacted level to finance the increase in the Federal minimum
    wage that will occur on July 24, 2009. ETA will focus its technical
    assistance efforts on transitioning seniors in programs funded by the
    Recovery Act into the regular 2010 program with minimal disruption.
    Job Corps
        The budget includes $1.7 billion to operate a nationwide network of
    124 Job Corps centers in fiscal year 2010. Job Corps provides training
    to address the individual needs of at-risk youth and ultimately equip
    them to become qualified candidates for the world of work. Job Corps
    received $250 million from the Recovery Act, which it is using to fund
    shovel-ready construction projects that stimulate job growth in center
    communities. In addition, the Recovery Act funds are promoting
    environmental stewardship in Job Corps by supporting development of
    green-collar job training, technology enhancements, and fleet
    efficiency.
    Veterans' Employment and Training Service
        When it comes to training and employment, we will never forget our
    commitment to our veterans. For the Department's Veterans' Employment
    and Training Service (VETS), the fiscal year 2010 budget request is
    $255 million and 234 FTE. The fiscal year 2010 budget includes $35
    million for the Homeless Veterans Reintegration Program (HVRP), an
    increase of $9 million (34 percent) above fiscal year 2009. The request
    will allow the program to provide employment and training assistance to
    an additional 7,200 homeless veterans, with an increased emphasis on
    aiding homeless women veterans. The budget also includes a $2 million
    increase for Veterans Workforce Investment Programs to provide services
    to veterans that will result in new skills and employment in Green
    Jobs. In addition, the budget requests an increase of $3.5 million to
    expand access to the Transition Assistance Program (TAP) for spouses
    and family members (including those with limited English proficiency).
    TAP Workshops play a key role in reducing jobless spells and helping
    servicemembers transition successfully to civilian employment.
        I place a strong priority on ensuring that the innovative programs
    I have described above are available to persons in all communities
    across our Nation, including those living in rural communities. I am
    eager to partner with my colleagues in the Cabinet and you to ensure
    this happens.
                    ensuring accountability and transparency
        Spending tax dollars wisely helps the Department achieve our
    mission on behalf of America's workers, and builds trust among our
    stakeholders. We are committed to ensuring a sense of responsibility,
    accountability, and transparency at the Department of Labor. Our fiscal
    year 2010 budget supports those goals.
    Workforce Data Quality Initiative
        The fiscal year 2010 budget requests $15 million for a Workforce
    Data Quality Initiative of competitive grants to support the
    development of longitudinal data systems that integrate education and
    workforce data. Longitudinal data systems track individuals as they
    progress through the education system and into the workforce. Some
    States have developed comprehensive systems that link individuals'
    demographic information, high school transcripts, college transcripts,
    and quarterly wage data. These data systems can provide valuable
    information to consumers, practitioners, policymakers, and researchers
    about the performance of education and workforce development programs.
        The Department will work to develop this grant program with input
    from the Department of Education. Grants will help States to
    incorporate workforce information into their longitudinal data systems,
    as well as undertake activities to improve the quality and
    accessibility of performance data reported by training providers.
    Improving information available from training providers is crucial to
    helping consumers make informed decisions when choosing among training
    programs.
    A Renewed Commitment to Program Evaluation
        In recent years, the Department's evaluation capacity has eroded,
    and it has funded too few high-quality evaluations of its programs. The
    administration and the Department recognize the need to conduct a
    rigorous evaluation agenda to determine which programs and
    interventions work and inform its policy, management, and resource
    allocation decisions. The fiscal year 2010 budget provides $5 million
    for a new Department-wide initiative to support rigorous evaluations
    across the Department of Labor. The new initiative will allow expansion
    of evaluation activities to other programs, with a priority on large,
    lightly examined, and/or high-priority programs. In addition, the
    budget requests an increase of $5 million for ETA's evaluation budget
    for job training and employment programs. As part of this initiative,
    the Department of Labor would look to build partnerships with the
    academic community and other outside parties to leverage private-sector
    research activities; make public its research and evaluation agenda,
    and develop the agenda based on feedback from the public, Congress, and
    its stakeholders.
                                 other programs
    Bureau of Labor Statistics
        In order to maintain the development of timely and accurate
    statistics on major labor market indicators, the fiscal year 2010
    budget provides the Bureau of Labor Statistics (BLS) with $611.6
    million and 2,416 FTE. This funding level provides BLS with the
    necessary resources to continue producing sensitive and critical
    economic data, including the Consumer Price Index (CPI) and the monthly
    Employment Situation report. In addition, the fiscal year 2010 budget
    includes an increase of $8 million and 10 FTE to produce new data on
    employment and wages for businesses whose primary activities can be
    defined as ``green,'' and produce information on the occupations
    involved in green economic activities.
    Office of Disability Employment Policy
        The fiscal year 2010 budget provides the Office of Disability
    Employment Policy (ODEP) with a total of $37 million and 49 FTE, an
    increase of $10 million (39 percent) over fiscal year 2009. With the
    increase, ODEP will support a new initiative that builds upon the
    lessons learned through the Work Incentive Grant demonstration
    Disability Navigators, and focuses on working with employers, the One-
    Stop system, and other stakeholders to vigorously promote the hiring,
    job placement, and retention of individuals with disabilities,
    particularly youth, in integrated employment, apprenticeship, and pre-
    apprenticeship programs, and community service activities. The fiscal
    year 2010 budget also proposes ``Add Us In!''--a new grant program for
    minority youth with disabilities who are transitioning from school
    (secondary or postsecondary) to employment and are interested in
    entrepreneurship. Financed within ODEP's base budget, the initiative
    would feature collaboration with minority chambers of commerce.
    Bureau of International Labor Affairs
        The fiscal year 2010 request for the Bureau of International Labor
    Affairs (ILAB) is $91.4 million and 95 FTE. The request provides an
    increase of $5.3 million and 12 FTE to allow ILAB to step up its
    monitoring and oversight of workers rights. This will involve closer
    monitoring and reporting on labor conditions worldwide, with a goal of
    reducing violations of worker rights and incidents of child labor,
    forced labor, and human trafficking. The fiscal year 2010 budget will
    maintain ILAB's child labor and worker rights activities at the fiscal
    year 2009 level
    Women's Bureau
        The fiscal year 2010 budget includes $10.6 million and 52 FTE for
    the Women's Bureau. This budget will allow the Women's Bureau to
    continue its mission of designing innovative projects addressing issues
    of importance to working women and providing information about programs
    and polices that help women attain high paying, career ladder jobs in
    nontraditional fields, including opportunities in green industry
    sectors and occupations.
                                   conclusion
        With the resources we have requested for fiscal year 2010, the
    Department will step up its enforcement of worker protection laws;
    provide innovative training and employment programs that promote green
    investments while ensuring diversity and inclusion; increase employment
    opportunities for our Nation's veterans and their families; and ensure
    our programs are accountable and understandable to the public and our
    stakeholders.
        Mr. Chairman, this is an overview of the programs proposed at the
    Department of Labor for fiscal year 2010. I am happy to respond to any
    questions that you may have.
        Thank you.

        Senator Harkin. Thank you very much, Madam Secretary.
    Again, I really appreciate the focus you've made getting back
    in the game on OSHA and worker protections. And what you're
    doing on dislocated workers, especially during this period of
    time, and on the green jobs. I just, again, commend you and
    President Obama for focusing on this area.
        And as I understand it, you're looking at the green jobs in
    different areas and different programs that you have under your
    jurisdiction. One of those is the Career Pathways Innovation
    Fund for community colleges. It's been my experience that a lot
    of these community colleges are the ones that are really in the
    forefront of developing curricula and teaching our kids these
    new green jobs technologies.
        And so I hope that the Pathways Fund will be used for
    getting more program information to community colleges for them
    to use for developing these new careers in renewable energy and
    wind energy and transportation. There are a lot of different
    things that they're teaching in the community colleges.
        Thank you very much for your increase in ODEP. This is
    something that we just can't fall back on and we've got to
    continue our efforts to get more people with disabilities
    employed. And of course the ILAB on keeping our position, as a
    leader in the world, and on getting rid of the worst forms of
    child labor.
        I remember--I was driving to work one day and I was
    listening to--what do I listen to in the morning, 81.5, WAMU--
    and it was talking about, this was a couple months ago--and
    about the impact that President Obama has had on young people.
    And there was--this inner city school teacher talking about how
    kids in her classroom were now, paying more attention and
    taking pride in their schoolwork.
        And she had this one kid, she said, who'd been noted as a
    trouble maker. And this kid said something like, ``They say I'm
    a trouble maker and my teacher says I'm impossible. Well, I
    want to be possible.'' And, I think that's the kind of spirit
    that has come from President Obama, that kids want to be
    possible.
        So, we've got to focus a lot on our minority youth in this
    country, and their training and their skills, and their
    education, and making sure that they can become possible, like
    this one young man said.
        So, that's your job. I mean, that's the job that I see at
    the Department of Labor, what you can do is you can really
    carry this out and focus on the areas of getting our young
    people trained for the careers of tomorrow.

                    EMPLOYMENT OF PERSONS WITH DISABILITIES

        The only questions I have is on the employment of persons
    with disabilities. You requested $10 million over last year, I
    thank you for that. But, then again, we look at a $17 million
    Disability Navigators Program that was funded through the Work
    Incentives Grants.
        Now those Disability Navigator Grants were often used to
    increase physical and program accessibility at your one-stop
    centers. Well, that's going away and now we have a $10 million
    increase. So, am I really looking at a $7 million decrease in
    funding?
        I'm just concerned about the wide-ranging problems with
    accessibility and participation of job seekers with
    disabilities in the one-stop system. Can you assure me that
    this issue, which was previously the focus of the Disability
    Navigators--that was funded under the Work Incentives Grant
    program--will continue to be a priority of this Department?
        Secretary Solis. Mr. Chairman, Senator Harkin, yes. I would
    say that one of the things that--and please keep in mind that I
    have only been in office, not even 3 months yet, and I did come
    in at a time when the budget was somewhat already being
    prepared.
        Senator Harkin. Right.
        Secretary Solis. So, it was very interesting to be in those
    discussions. But I continue to remain very supportive of the
    notion that we have to really fully integrate services for our
    disabled population, at every point in our agency, where we
    can. So, not just at the one-stops, but also in our efforts--
    and I think I may have mentioned this at our confirmation
    hearing--we're going to see an unusually large number of
    returning veterans, that are going to have severe brain injury
    and traumatic stress.
        We also need to expand what we do with the disabled
    community, in addition to those that are currently here and
    have not found employment. And I would hope that our State
    agencies will work with us now, because these demonstration
    programs that you note, the Navigator Program, have been in
    existence--and they were supposed to be demonstration
    projects--the funding has now been fully exercised there. My
    hope is to get, and our directives are, that the State agencies
    will pick up that responsibility, as well.
        So, I'm going to do whatever I can to make sure that
    happens, and then hopefully work with this subcommittee to see
    that we can increase our efforts to collaborate, not just
    within DOL, but also with DOE, and with other agencies, the
    Veterans Administration as well, to see how we can expand the
    services and work intersegmentally with these other agencies,
    and also have pools of money, where we can do a little bit
    better targeting.
        I think this is going to be a great opportunity for us. I'm
    very excited. Once I have my leadership in place in ODEP, that
    we're going to have, I think, some very innovative strategies
    to bring back to you in this subcommittee.
        Senator Harkin. I appreciate that. Well, I look forward to
    working with you in that area.
        I have another question, but I will do it in another round
    if we have time. At this point, I just yield to Senator
    Cochran.

                           GULFPORT JOBS CORPS CENTER

        Senator Cochran. Mr. Chairman, thank you very much.
        Madam Secretary, we appreciate the call you made the other
    day to advise us of the release of--of funds under the National
    Emergency Grants (NEG)--there are more acronyms in this budget
    than in any budget--it's the National Emergency Grant, and it
    was an extension of a grant that had been made and approved to
    the State of Mississippi by the Department of Labor. And they
    had requested additional funding, and your call indicated that
    that had been approved. And I just wanted to thank you for
    that, and encourage the Department to continue to monitor the
    needs that exist on the Mississippi Gulf Coast, as a result of
    Hurricane Katrina.
        One example, is a Job Corps center that was destroyed in
    the hurricane, and it has not been rebuilt. We were hopeful
    that funds would be made available for the Gulfport Jobs Corps
    Center. And it was scheduled to be opened, reopened in August
    of this year. There's an interim modular building, I think,
    being used right now for about 150 students, but we hope that
    that can be accelerated and we can move toward a completion of
    that center at an early date.
        Do you have anything in your notes about that?
        Secretary Solis. Yes, I do, Senator Cochran. And, I realize
    that I also inherited this--this challenge, and we will work
    diligently to try to really streamline the process so that we
    can get this up and moving in, hopefully, a shorter timeframe;
    2011, I believe is what we're looking at, to fully operate the
    Job Corps Center. And meanwhile, as you said, we do have other
    transitional modulars that are out there to help with the
    different Job Corps students that need assistance.
        I do want to mention that during Katrina and the recovery
    effort, that the Youth Build Program was very, very involved in
    helping to provide assistance, construction, other types of
    exercises that they were fully involved in. So our programs are
    working, and I just wanted to report that to you, that we're
    watching and monitoring and want to continue to work with you
    and to see that this Job Corps Program is fully implemented and
    that it's up to speed and ready to go, in a shorter period of
    time.
        Senator Cochran. Well, we appreciate your personal interest
    in that goal, and thank you for your attention to that. We had
    in our committee report that that Youth Build Program, which
    specifically was actively engaged in the construction of new
    homes and helping rebuild neighborhoods and communities all
    along the Gulf of Mexico. So, we appreciate that.

                           DISLOCATED WORKER PROGRAM

        There was a decrease in funding, that we were advised
    about, for the State of Mississippi of 50.4 percent, a
    reduction which amounts to $13.8 million below the amount the
    State received in WIA funds in fiscal year 2008. I'm advised
    that funds are distributed to States based on the State's
    unemployment rate and the rise in its unemployment rate
    compared--as compared with other States.
        I think what has happened is, that in other States,
    unemployment rates have increased over the previous years, at a
    higher level than they did in Mississippi, and so our State
    ended up getting a decrease in funding, as compared with--with
    the funds received from other States. Is there any--is there
    any plan to address that or to make a request for supplemental
    funding, so that a State can be held harmless? The unemployment
    rate is still high, there are probably more people unemployed
    than there were last year, but because other States have much
    higher unemployment rates, Mississippi loses money and it gets
    transferred to other States. That's the way I read that.
        Secretary Solis. Yes.
        Senator Cochran. Is that the way that program works?
        Secretary Solis. Unfortunately, you hit it right on the
    nose, Senator. The program you're talking about is Dislocated
    Worker Funding, and it's a formula-based funding. So, those
    formulas are set by--by you, the Senate and the Congress. And
    unfortunately, I understand this is an issue that we may want
    to address as we go through WIA reauthorization. I know some
    members are very concerned about this. And I also agree that
    something has to be done.
        In my request, before you, I'm asking for an additional $71
    million in the NEG, so we can address this issue as soon as we
    can. That isn't the cure-all though; the long-term problem is
    we have to fix the formula so that when crises like this occur.
    We are hoping to be able to not penalize States and hold them
    harmless when they're--when you see continuing unemployment
    rate that just is not going down over a period of 2 years.
        The program wasn't intended to fund as many States in this
    manner, is what I believe, and so, yes, this is a crisis and we
    have to take measures to modify that. So I will work--I would
    love to work with you, Senator, and with this subcommittee, and
    other members who have already expressed concern about this
    issue.
        Senator Cochran. Thank you very much.
        Senator Harkin. Thank you, Senator Cochran.
        Senator Murray.
        Senator Murray. Thank you very much.
        And, Secretary Solis, welcome to this subcommittee. Thank
    you for your conversation yesterday and for all the work that
    you are doing. I really appreciate you having this hearing
    today.
        Following up on Senator Cochran, I had a question on the
    same thing, because this does have to do with the distribution
    of the WIA funds for the Dislocated Worker Program. When we
    originally set up the formula for this, it was meant to be
    dynamic so that it could react to the ebb and flow of a
    turbulent economy, but the formula has actually now impacted
    some States in a negative way. And we are going to have to
    figure out how to do that in the future, so that we don't end
    up in a situation--my State is estimated to lose about $200
    million under the current challenge that we've got.
        You mentioned using some of the NEG to fill in the gaps. Do
    you need an additional appropriation from the Senate bill to do
    that or are you going to use what you currently have until we
    can meet those obligations?
        Secretary Solis. Senator Murray, thank you for your
    question. We're going to try to exhaust the $1.2 billion
    that's--that has been provided in the Recovery Act, and I'm
    assuming that that may go more quickly than we assume. So, we
    are requesting the $71 million to help--to help that.
        Senator Murray. Okay, could you let us know where you are
    with that formula--or with the NEG grants and where the
    shortfalls are, and when you expect to hit them, because a
    number of States have been impacted?
        Secretary Solis. Absolutely.
        Senator Murray. Okay, thank you.

                       PELL GRANTS FOR UNEMPLOYED WORKERS

        I wanted to ask you--on Friday, the President announced an
    initiative to ensure that those who are unemployed will be
    eligible for Pell Grants. Has your budget team and the budget
    team of the Department of Education (DOE) come up with an
    estimate of the amount of funds that will be necessary to carry
    out that extension?
        Secretary Solis. Senator Murray, as I spoke with you
    regarding this issue, we are--we are now looking at how this
    program will be implemented. I don't have that figure in front
    of me at this moment, because our staff is working on that now.
    But I know this is something that--I know you have a great deal
    of concern and I expressed to you that I--through your
    leadership, we want to work with you to make sure that we do
    the best, in terms of implementing this, and try to do the
    best, in terms of delivery and efficiency.
        I think it's an exciting program. I'm not sure quite how
    DOE and ourselves will have all the mechanics, but I know our
    staff is working on it. It's an exciting topic, but I have
    similar concerns that you might have.
        Senator Murray. I agree that it's much needed and, you
    know, in the right direction. I just want to know what our--our
    cost is going to be and how that's going to be appropriated or
    if it will come from other funds. So if you can work with the
    Department of Education and come back and let us know what the
    costs of that are going to be.
        Are you considering expanding that to immediate family
    members or does the proposal include immediate family members,
    children of unemployed workers, or is it just the worker
    themselves?
        Secretary Solis. I don't have all the specific details
    because this has just been rolled out Friday, but my
    understanding, it's for unemployed workers--we haven't really
    discussed what other family members would be impacted.
        So, certainly I will get back to you as soon as I can, and
    possibly later today.
        Senator Murray. Okay, I appreciate that very much.

                              FUNDS FOR JOB CORPS

        Also, I wanted to ask you about the funds for Job Corps,
    which is the largest program in the Federal Government to help
    our at-risk youth. It targets some of our hardest-to-serve 16
    to 24-year-olds, many of them with criminal records, most of
    them with poor reading and math skills, and probably with very
    limited attachment to any kind of school or labor market.
        I have been told that this is a time when our young adults
    are facing the worst job market since World War II, so I am
    following the Job Corps very closely; I think it's a very
    important part of our dealing with that challenge. It's a
    public/private partnership with 94 of the 122 Job Corps Centers
    that are run today by corporations and private, not-for-profit
    organizations, and it is a competitively awarded contract. I
    think it's a really good program.
        I was concerned it was flat-funded in your budget request.
    Do you think this is a program that needs to have some
    increased cost, particularly at this economic time when a lot
    of our kids are facing some real challenges?
        Secretary Solis. I think that what we're looking at right
    now is still the $37 million that was provided through the
    Recovery Act. That was a substantial increase, overall. So,
    that also does set somewhat of a precedent.
        What I'm looking at now is trying to make sure that we can,
    also as Senator Harkin was saying earlier, the chairman, about
    trying to make sure that these programs really have career
    ladders, that we also look at opportunities to go to a
    community college, or a tech or vocational school and get a
    certificate, but also green these programs. So, that's also
    going to take additional focus and funds.
        Job Corps programs, I think, are wonderful. I've seen them
    in effect even here in the District, in D.C., and they're not
    all green jobs--obviously you have people that are going into
    healthcare, and I think that there's--it's worthwhile to have a
    discussion, to see how there can be some innovation provided in
    Job Corps.
        I think their goal, the focused population that they have,
    is well-meaning. But I do think there can be more that we can
    provide, in terms of assistance.
        Yesterday, when I spoke before the Appropriations Committee
    in the House, there were concerns, also, about funding that may
    not be as exuberant at this time----
        Senator Murray. I appreciate that the Economic Recovery
    package has money for this, but if we don't have long-term,
    sustained requests for beyond the timeframe of the Economic
    Recovery package, we're going to be in a very bad place.
        So, this is something I care a lot about, Mr. Chairman, and
    I hope we can work it out.
        Secretary Solis. Senator Murray, if I can just explain,
    also, one of the things I would like to do as Secretary of
    Labor, is to put Job Corps back with the other programs in the
    Employment and Training Administration.
        Senator Murray. I saw that proposal, actually.
        Secretary Solis. And really try to make more meaningful,
    what we're doing with all of our youth. So there is more
    coordination, there's no overlap, and that we really focus in,
    in a more meaningful way. And this will be a good opportunity,
    and that's a prerogative that I have as Secretary of Labor.

                               PREPARED STATEMENT

        Senator Murray. Okay, very good. I appreciate that.
        Thank you.
        [The statement follows:]
                   Prepared Statement of Senator Patty Murray
        Thank you, Mr. Chairman, for holding this hearing to examine the
    President's fiscal year 2010 budget proposal for the Department of
    Labor.
        I would also like to extend my appreciation to Secretary Solis for
    coming before this subcommittee to discuss the administration's
    proposal.
        America's working families are facing some of the toughest economic
    challenges in a generation. As of last month, more than 13 million
    people were unemployed in this country. And, we've lost 5.7 million
    jobs since the recession began.
        Too many parents are forced to choose between going to work and
    taking care of a sick child. Families are struggling to pay tuition, or
    keep food on the table--and many depend on weekly unemployment
    insurance benefits because the pool of jobs has dried up in their
    communities.
        America's working families are looking for hope, and they are
    looking for a champion. Hope that they'll be able to stand on their own
    once again, and a champion to stand up for them when they aren't able
    to stand up for themselves.
        And I believe that a restored and focused Labor Department can do
    just that--it can help the millions of unemployed job seekers find
    training for careers in new, growing industries. It can help them
    access the benefits they need to get by until they can stand on their
    own again. It can help keep them safe and healthy in the workplace, and
    guard against unfair labor practices. And, it can be their advocate at
    the highest levels of the administration during this economic recovery.
        I believe that this administration is committed to making working
    families a priority once again in this country.
        And, for the most part, the President's budget proposal for the
    Department of Labor reflects that commitment.
        As the chair of the Subcommittee on Employment and Workplace
    Safety, I was particularly encouraged to see the significant
    investments in labor protections and workplace safety and health across
    the Department. I was pleased to see a proposal to strengthen State
    Occupational Safety and Health Administration (OSHA) programs, like the
    one in my home State of Washington, that extend the work of national
    OSHA, but, for too long, have not had sufficient resources.
        And, I'm glad to see a renewed investment in quality data,
    evaluation, and reports so that Congress and the public can clearly see
    which efforts work and which don't.
        I was also pleased to see an effort to move Job Corp back to the
    Employment and Training Administration where it belongs.
        And as the author of the Promoting Innovations to the 21st Century
    Act, a bill focused on career pathways for young people, I was very
    pleased to see a focus on pathways under the Workforce Investment Act
    programs.
        While I'm very pleased with most of the budget, I do have some
    concerns about the priorities reflected in the Workforce Investment Act
    proposed levels.
        I appreciate the fact that the Department did not cut these funds,
    but I had hoped for a significant investment in job training programs--
    particularly as our Nation works to recover from this recession.
        I fought for the Recovery Act to include a $4.2 billion investment
    in jobs training, a much needed shot in the arm for a system that's
    been neglected during the last administration and had its capacity to
    serve large numbers of job seekers severely diminished.
        And while this was a strong step in the right direction, I believe
    that we need to do more to rebuild the system's capacity and adequately
    serve our workers.
        For example, those areas that are rebuilding their summer youth
    programs with the investment we made in the Recovery Act, may not be
    able to sustain them at the recommended 2010 levels.
        I hope that as we move forward and learn more about the impacts of
    the Recovery Act funds, that you will work with me and this
    subcommittee to strengthen and focus our investments in education and
    training for America's workers.
        As we've discussed several times, I'm committed to reauthorizing
    the Workforce Investment Act. And I want to ensure we're investing in
    our workers to help them get the training they need to fill the high-
    skill, high-wage jobs of the future, and help get our economy back on
    track.
        I'm also concerned that the proposal for Job Corps funding levels
    sends the wrong message. It's a valuable program that serves as a
    second chance for many youth in our country, and in these tough
    economic times I think it should be a priority.
        And, while the funding levels for the Senior Community Service
    Employment Program received a bump, it only covers the minimum wage
    increase. And, it still serves less than 1 percent of the eligible
    population, low-income older workers who struggle to find jobs. I hope
    that you will work with Congress to find a solution that strengthens
    this program moving forward.
        I look forward to hearing from you today, Secretary Solis, and to
    our continued partnership.

        Senator Harkin. Thank you, Senator Murray.
        Senator Pryor.
        Senator Pryor. Thank you, Mr. Chairman.

                        COBRA PREMIUM ASSISTANCE PROGRAM

        Madam Secretary, let me start with a question that is more
    immediate, and that is on the COBRA Premium Assistance program,
    I think you mentioned it in your opening statement.
        We've had--and I'm sure that the other Senators have had--
    lots of calls and concerns and confusion about--from unemployed
    workers--about the COBRA provision in the Recovery Package. Can
    you just give the subcommittee, here, a little update on the
    initiative you're working on, and how the effort is going to be
    set up?
        Secretary Solis. There is--thank you, Senator--there is a
    lot of interest in the program. In fact, reports we're getting
    back from our regional offices is that there's an overwhelming
    number of individuals, participants, who want to know how to
    get involved in the program. And it is----
        Senator Pryor. We get a lot of those calls, too.
        Secretary Solis. There's a lot of calls. In fact, I'm not
    quite sure that our systems are really prepared to receive all
    of those incoming calls.
        I know that there will be--that we are anticipating that
    there will probably be a process that may prolong itself in
    terms of appeals that might be made, because there also has to
    be substantiation of where the individual was working. So, that
    will require some backup, or it will happen as a consequence of
    all of these calls.
        So, I am concerned about that, and our staff is doing
    everything we can. I don't have my full leadership in place,
    yet, so that's also been a hindrance, because I have to rely on
    the current staff that are there.
        So, it's a challenge, but it's one that I know we are very,
    very focused on, and we'd like to get back to you with more
    details.

                           UNEMPLOYMENT OVERPAYMENTS

        Senator Pryor. Okay, let me ask, if I can, about
    unemployment insurance. There's a--in the budget the
    administration puts forward an idea to reduce unemployment
    overpayments by about $3.9 billion. What is going on in this
    system where, you know, it sounds like $3.9 billion, you've got
    a lot of people who are overpaying every year. Can we fix that
    system? Do you feel like the Department of Labor is on top of
    that?
        Secretary Solis. That is going to be a priority for this
    Department. This also came up yesterday in our hearings before
    the House appropriators, and it is something that we know we
    will need resources to do a better job to focus here, to go
    after those fraudulent claims and collect that money.
        So, it will be a priority for this new administration.

                             EMPLOYMENT STATISTICS

        Senator Pryor. One of the things that your Department does,
    it may be kind of mundane, but that's important to a lot of
    people that statistics are tracked by the Bureau of Labor
    Statistics. I know, last year we had someone calling our
    office, they were trying to get a handle on--I think it may
    have been on an economic development issue, I don't recall
    right now, but they were trying to get a handle on some real
    specific statistics for Arkansas. And basically, I think what
    they wanted was local employment statistics, and the Bureau of
    Labor Statistics told us that they're no longer collecting or
    disseminating the specific statistic my constituent wanted.
        And I notice in the budget there's an $8 million increase
    for the BLS, Bureau of Labor Statistics--do you know if you are
    going to restore some of the things that you used to do? Do you
    know anything about that?
        Secretary Solis. Senator, I don't know specifically about
    the response with respect to your State, but certainly the
    monies that we are requesting will go into also helping to look
    at jobs in the green industry, but also looking at where we are
    not doing a good job in terms of gathering data on
    disabilities, on different populations.
        And certainly, one of my concerns, as a former member of
    the House, was always wanting to have a quick response in terms
    of what our cities, our locales, what those figures were. And I
    can tell you in all honesty, that I would always look up in my
    local paper, what the local States have, because they typically
    have the best information. I know that our Bureau coordinates,
    but we need to have a better approach to having that more
    immediately.
        So, I know I will be working very closely, I think this is
    something very important, and we do have to reconfigure what, I
    believe, some of the priorities are in the BLS. And of course,
    this is going to be a challenge, and we'll need to work closely
    on this.
        Senator Pryor. Great, thank you.

                   VETERANS' EMPLOYMENT AND TRAINING SERVICE

        And the last question I had was about, something that's a
    follow-up to one of your earlier questions and your opening
    statement, the Veterans' Employment and Training Service--you
    have the request of $225 million. Do you feel like that's
    sufficient, given the fact that we have so many folks coming
    back from Iraq and Afghanistan and given the tempo that the
    military's been at, recently. Do you feel like that $255
    million is sufficient?
        Secretary Solis. Senator, I want to be as honest as I can.
    I still have yet to be able to place my leadership team
    together in that particular unit, so I'm awaiting that. But my
    personal commitment is that we need to do everything we can to
    coordinate with other Federal agencies. We certainly have a key
    component in helping to help folks that are coming back to get
    back into their job, and we're finding that a lot of veterans
    are not being re-employed. That is going to, obviously, take a
    lot of effort, and hours to do that.
        But we also want to expand how we work with veterans and
    with their families and their spouses. That's an initiative
    that the President's wife, Michelle Obama, is also taking on,
    which I take very seriously.
        So, I want to try to integrate as many things as I can with
    the current resources and the other agencies that can help us
    do that. Because it's going to--it's going to require what I
    would say are more wrap-around services, to really help address
    the issues of these returning soldiers.
        So I agree with you, this has to be a priority, and we'd
    like to work with you to see how we can really formalize a good
    program, because this is going to be ongoing.

                               PREPARED STATEMENT

        Senator Pryor. Thank you. Thank you, Mr. Chairman.
        [The statement follows:]
                    Prepared Statement of Senator Mark Pryor
        Thank you Chairman Harkin and Senator Cochran for holding this
    subcommittee hearing concerning the budget request for the United
    States Department of Labor.
        I appreciate Secretary Hilda Solis appearing before this
    subcommittee today.
        The Department of Labor is responsible for protecting wages and
    working conditions for 135 million workers in more than 7.3 million
    workplaces.
        As the country faces its most profound economic downturn since the
    Great Depression, it is critical that we meet our responsibilities to
    unemployed workers and that we take the steps necessary to ensure that
    workers are trained or retrained in the skills that are needed to keep
    our country competitive.
        I look forward to hearing Secretary Solis' testimony and having the
    opportunity to ask questions.

        Senator Harkin. Thank you, Senator Pryor.

                            FAIR LABOR STANDARDS ACT

        Madam Secretary, in March I held a hearing on the
    Department's oversight of what we call the 14-C Program under
    the Fair Labor Standards Act. And this arose out of a terrible
    situation that was uncovered in my State of Iowa.
        The 14-C Program, as you know, is a program that allows
    employers to pay subminimum wages--subminimum wages--to
    individuals with disabilities, especially individuals with
    intellectual disabilities--because they maybe can't produce as
    much. They have a program that allows them to pay subminimum
    wages; it's been in the law for a long time.
        Now, here's what happened, though. In this situation which
    came to light, and it's been going on for many years, like 30-
    some years--individuals with intellectual disabilities, what we
    might call mentally retarded in the past, were hired by a
    company in Texas--Henry's Turkey Service. They were put on a
    bus and shipped to Iowa, to work at a Turkey plant in southeast
    Iowa. These were all men. They were then put up in a kind of a
    rooming house, which was an old abandoned schoolhouse, and they
    got up at 3 or 4 in the morning, got on a bus, went to work
    there at this plant. Many of them worked right alongside of the
    other workers, doing the same work that the workers were doing.
        They were housed in this schoolhouse--I think the monthly
    rental on that whole school is, like, $600 a month, for the
    whole building. And yet each of these--how many were there?
    Twenty-some individuals, were charged $1,200 a month for their
    rent. And that was taken out of their pay--that was taken out
    of their pay.
        And so this situation was uncovered, but that--the thing
    that was startling was not--was how bad this was, but the fact
    that it had gone on for years, and no one knew about it.
        And then the more I dug into it, the more I found out. This
    company--their 14-C application had expired, and you have to
    get it renewed every couple of years. And it expired, and yet
    nothing was done--it just expired.
        And so the hearing I held was on this issue of, how could
    this happen? And how many people is the country are we talking
    about? Is this just some isolated little incident that we don't
    need to change anything for?
        Well, a GAO report I found out about indicated in 2001,
    (GAO-01-886) there were approximately 424,000 workers in
    America, paid subminimum wages. These are people with
    intellectual disabilities, mental retardation, most of them.
        Well, it's also come to my attention that the Department of
    Labor--this Department of Labor--really has a minimal number of
    people working on this, and it's all done by paper. They send
    the paper out, the employer fills it out, sends it back in and
    says, ``Yes, I'm under the 14-C Program,'' and that's it, then
    they file it, and that's it.
        Federal inspectors had been at this plant once, some years
    ago, and nothing was done. It wasn't until a local worker, a
    State worker had uncovered this that it all came to light what
    was going on. People--some of these men had been working there
    for, like, 20 years, and had nothing to show for it--they had
    no retirement, they had no benefits, they had nothing. Some of
    them work in there every day, 8 hours a day, 40 hours a week,
    sometimes overtime, and some of them had, like $6 a month
    leftover. I mean, this was a scandal. And it just--you think,
    how could that happen in America?
        Well, I tell you this story because it's something I want
    to work with you on, and we've got to get a better handle on
    this 14-C Program. And I'm developing some legislation. But I
    think there's a lot that can be done administratively on this,
    to tighten down and make sure that people who are applying for
    14-C exemptions actually are doing what they say they're doing.
    That the people qualify, and that they really are doing work at
    a reduced rate, you know what I'm saying, they're not as
    productive.
        I'm not against the 14-C Program, don't get me wrong. It
    can be a good thing for a lot of people with severe
    disabilities to actually have some employment. But, obviously,
    if they can't produce much, then you pay them a little bit
    less--I understand that.
        But, I wanted to make sure that they're actually--are they
    actually, really, so disabled that they can not make at least
    the minimum wage, or more, if you get my point.
        Secretary Solis. Yes.
        Senator Harkin. Somebody has to make those determinations.
    It's all done by paper, now, we have no inspectors, going out
    there and checking up on this and finding out what's going on,
    so how widespread this is? I don't know. I just know from my
    2001 report that there's approximately 424,000 workers at GAO.
        So we need monitoring, and bring this up to ask you, and
    your Department to get people paying attention to this. I would
    like to come back with you on this to find out what it is,
    administratively, that you can do, and what it is that we need
    to do legislatively to fix this.
        So I hope we can have cooperation on this, and also your
    attention to this one factor. These are the most vulnerable
    people in our society, and the fact that they can be treated
    like this is just unconscionable.
        So, I hope we can work with you on that.
        Secretary Solis. Senator, thank you for your comments, and
    I too was horrified when I read the article, and articles
    surrounding this issue.
        And I know that in the last 8 years, we have not had
    sufficient investigators in the Wage and Hour Division, and
    hopefully our budget request will help us begin to address
    that, so we could put real bodies, real investigators out in
    the field, to look at these kinds of industries that take
    advantage of these most vulnerable populations.
        And I want to thank you for your leadership in drawing to
    our attention the fact that we need to do more collaboration on
    the 14-C applications, along with trying to collaborate better
    with the Social Security Administration also, so that we can
    identify who these individuals are, and also who is drawing
    down the 14-C applications so that we do get rid of the bad
    actors, and that we send a strong message that this is not
    going to be tolerated.
        So, I want to work with you on it, I'll be excited to hear
    what ideas you have surrounding the program.
        Senator Harkin. Okay, thank you very much, Madam Secretary.
        Senator Pryor, do you have any more questions?

                              SENATE CONFIRMATIONS

        Well, Madam Secretary, we have no more questions here, if
    we have other questions, we'll submit them in writing, but
    again, do you have anything that you want to draw our attention
    to, here, regarding your budget, that you think that we didn't
    cover that you would like to bring up?
        Secretary Solis. Well, there is one concern that I have,
    and that is just that I know that we're a new administration,
    and it's hard right now to process the number of people that
    we'd like to bring in to help with our leadership in our
    Department.
        Yesterday, I was asked this question by Chairman Obey--he
    asked me, facetiously--how many people we have actually gotten
    through the process and confirmed by the Senate, and I could
    only tell him two, and one of them is sitting behind me here.
        So, you know that we have a tremendous effort ahead of us,
    and we want to be able to show that we're working effectively,
    transparently, but also accountable to you. I would just ask,
    and urge, the members of the Senate, if you can pass that
    along, that would be appreciated.
        Senator Harkin. Well, do you have some pending up here,
    right now?
        Secretary Solis. We do.
        Senator Harkin. How many?
        Secretary Solis. Two, we have two.
        Senator Harkin. Two that are pending, right now?
        Secretary Solis. Yes.
        Senator Harkin. Are they before our subcommittee? Not, I
    mean, not this subcommittee--the other committee I'm on.
        Secretary Solis. Before the HELP Committee.
        Senator Harkin. The other committee I'm on, the HELP
    Committee, right?
        Secretary Solis. Some of you have, yes, yes.
        Senator Harkin. They're pending before that?
        Secretary Solis. Yes, before the HELP Committee. Yes.
        Senator Harkin. Two pending before the HELP Committee.
        Secretary Solis. Any effort and energy would be much
    appreciated.
        Senator Harkin. Okay, we'll look at that.
        Secretary Solis. Thank you.
        Senator Harkin. We'll see if we can get that done as soon
    as possible.
        Secretary Solis. Thank you for your indulgence.
        [Clerk's Note.--Senator Inouye has submitted information
    about economic dislocation now taking place in American Samoa
    which will be inserted into the record.]

        Mr. Chairman and Madam Secretary: I would like to draw your
    attention to the economic dislocation now taking place in a remote part
    of the Nation--American Samoa--which is often treated as an after-
    thought. As you are aware, the Congress, under Public Law 110-28 (May
    25, 2007), increased the Federal minimum wage. At that time,
    investigation into unlawful lobbying activities learned of employment
    abuses by American garment manufacturing interests in the western
    Pacific. This led the Congress to include in Public Law 110-28 an
    immediate $0.50 cent increase of the hourly minimum wage in the
    Commonwealth of the Northern Marianas as of July 24, 2007 with an
    additional $0.50 cent increase every May 25 thereafter until the hourly
    rate matches the Federal rate of $7.25.
        In the rush to legislate, the Congress applied the same mandate to
    American Samoa without much consideration at all. In so doing, the
    Congress ended the biennial administrative minimum wage increases for
    American Samoa and imposed on this territory the fixed increases set
    for the Marianas. Unlike the Marianas, American Samoa was subject to
    the minimum wage requirement in the Federal Fair Labor Standards Act of
    1938. Recognizing the territory's developing economy, Congress had
    directed that the minimum wage in American Samoa should reach parity
    with the States ``as rapidly as is economically feasible without
    curtailing employment.'' The Fair Labor Standards Act thus applied to
    American Samoa the same statutory process that had gradually raised the
    minimum wage in the Virgin Islands and Puerto Rico to match the regular
    Federal rate. Under this procedure, your Department had adjusted the
    minimum wage rate in American Samoa every 2 years based on economic
    development in different sectors.
        Public Law 110-28, however, scrapped this procedure and mandated
    annual increases without regard to economic sustainability in American
    Samoa. In a subsequent report to Congress your Department noted the
    fragile condition of economic development in the American Samoa. In
    view of the territory's level of development, the Department observed
    that the mandated wage increase for American Samoa is equivalent to
    imposing a $16.50 Federal minimum wage requirements on the States. Your
    Department diplomatically added: ``General experience in the U.S. and
    elsewhere has shown that potential adverse employment effects of
    minimum wage increases can be . . . offset to some degree by an
    expanding economy that is generating net employment growth. In a
    declining economy, any adverse effects on employment will not be
    offset.''
        Although the Congress has ignored this report, the Department's
    assessment has proven all too accurate. The adverse employment effects
    are seen in the fish canning industry which directly and indirectly
    provides one-half to two-thirds of employment in American Samoa. This
    is particularly the case, since low-cost foreign competitors provide
    the same product at far lower prices. One canner in American Samoa has
    instituted severe employment cutbacks and the other canner will soon
    move its operations to a foreign country with lower costs.
        I would like to submit into the record, a letter I recently
    received from Congressman Eni Faleomavaega, requesting emergency
    assistance for American Samoa. Under the American Recovery and
    Reinvestment Act of 2009, Congress appropriated funds and authorized
    your Department to deal with economic dislocations just as in this
    case. I, therefore, urge you and your Department to consider the
    economic adjustment American Samoa faces and to extend the necessary
    assistance authorized under the Recovery Act.

                         ADDITIONAL COMMITTEE QUESTIONS

        Senator Harkin. The subcommittee will be submitting any
    additional questions for your response.
        [The following questions were not asked at the hearing, but
    were submitted to the Department for response subsequent to the
    hearing:]
                   Questions Submitted by Senator Tom Harkin
                         wia dislocated worker formula
        Question. When comparing regular 2009 program year allocations with
    2008 program year allocations, several States, including Iowa, will
    experience reductions under the Workforce Investment Act (WIA)
    Dislocated Worker formula. Iowa's unemployment rate is not as high as
    other States and began seeing job loss and increasing unemployment
    claims at the end of calendar year 2008 which has continued into 2009.
    However, under the 2009 program year allocations Iowa will receive a
    cut of 15 percent comparing the regular 2008 allocation with the
    regular 2009 allocation.
        What is the Department's view of the current dislocated worker
    formula and whether it effectively targets resources to the communities
    and States most impacted by recent economic dislocations? What changes
    could be taken during WIA reauthorization to ensure that States have
    more certainty about the level of funding they will have from year-to-
    year, while more effectively targeting formula funds to States and
    local communities that are experiencing recent significant
    dislocations?
        Answer. The WIA funding formula for dislocated workers was adopted
    from the one established under Job Training Partnership Act in 1982 and
    has not been revised since WIA's enactment in 1998. Although the
    formula focuses on targeting the funds to those States hardest hit by
    worker dislocations, wide fluctuations in funding amounts--such as
    those experienced with the program year 2009 allocations--are not good
    for the workforce system or the workers served by it. Features such as
    ``hold harmless'' or ``stop gain'' amounts could be built into the
    formula to moderate large fluctuations in funding on a year-to-year
    basis. A recent Government Accountability Office review provided
    Congress with several recommendations regarding WIA funding formulas.
    We look forward to working with the Congress through WIA
    reauthorization to examine these recommendations and other options for
    updating and improving the dislocated worker funding formula.
                        contracting authority under wia
        Question. The Recovery Act provided local workforce boards with the
    authority to contract with institutions of higher education or other
    eligible training providers if it would facilitate the training of
    multiple individuals in high-demand occupations and not limit customer
    choice.
        While it is still early in implementation of the Recovery Act, what
    has been the Department of Labor's (DOL) observation on the use of this
    authority? Does it provide an effective and efficient mechanism for
    providing support for training at the local level?
        Answer. This provision was very well received by the workforce
    system. However, it is too early to determine the effectiveness of this
    provision since we do not yet have information on its use. We will be
    reviewing the effectiveness of this authority and its use as part of
    our overall evaluation of the implementation of workforce provisions
    under the Recovery Act.
                       workforce data quality initiative
        Question. The budget includes a request for $15 million for a
    workforce data quality initiative. Since 2003, the subcommittee has
    supported funding at the Department of Education for Statewide
    Longitudinal Data systems. The 2009 appropriations act and Recovery Act
    included the authority for the Department of Education to make awards
    under this program for systems that included postsecondary and
    workforce information and provided more than $300 million for this
    purpose. How is the Department of Labor working with the Department of
    Education to ensure that the grant application for awards under the
    Recovery Act incorporate a request for proposals that would integrate
    useful workforce information into these systems? Haven't States
    received grants for this purpose under the recent Department of
    Education competition? The budget request also mentions that the $15
    million request would be available to undertake ``activities to improve
    the quality and accessibility of performance data reported by training
    providers''. What specific activities would be supported under such a
    grant solicitation and how much of the $15 million request would DOL
    reserve for such activities?
        Answer. The Department of Labor has an active partnership with the
    Department of Education (ED) to assure that our respective initiatives
    are not duplicative and represent value-added investments in building
    longitudinal data systems that link education and workforce databases
    at the State level.
        The Department of Labor (DOL) has already provided ED with
    information about the various workforce data systems that currently
    exist, as well as information about initiatives such as the Employment
    and Training Administration-supported Administrative Data Research and
    Evaluation project that uses longitudinal administrative data for
    employment and training research and analysis. DOL has also aided ED in
    shaping its ARRA-funded solicitation as it pertains to effectively
    linking workforce and education databases. DOL will engage in a similar
    consultation with ED as the solicitation for the Workforce Data Quality
    (WDQ) initiative is developed.
        I am requesting $15 million for the WDQ in the fiscal year 2010
    budget. The WDQ would focus on improving the quality of State workforce
    information and databases, so that workforce data are ready to be
    linked to educational data with funding provided by ED. Thus, the WDQ
    initiative would enhance, rather than duplicate, the Department of
    Education's investments. Specific activities that would be supported
    under the grant solicitation include the following:
      --The WDQ would provide resources to help States promote improvements
            in the quality and accessibility of performance data reported
            by training providers. Consistent and accurate data from
            providers about the services they offer and how these services
            impact their customers when they enter the labor market are
            crucial to informing researchers and consumers. Activities
            funded by the grants might include technical assistance to
            training providers or the development of a user-friendly
            interface to help training providers more easily report
            information on employment outcomes.
      --Grant funds may be used to enhance State workforce longitudinal
            administrative data systems by improving interoperability with
            education data or expanding the types of workforce data they
            contain. For example, Unemployment Insurance (UI) wage records,
            which are the primary source of workforce data, do not contain
            information on many Government or military employees, so some
            States have linked UI wage records to additional workforce
            data.
        Other focus areas of the WDQ would be developed in consultation
    with the ED to avoid counterproductive duplication of content and to
    assure that the WDQ investment adds to the robustness of State
    longitudinal data systems.
                       dol review of ex-offender programs
        Question. The congressional budget justification indicates that the
    Department is conducting a thorough review of current grants for ex-
    offender programs and will develop, in cooperation with the Department
    of Justice, a detailed plan for fiscal year 2010 funding.
        What were the findings from the DOL review of ex-offender programs?
    Specifically, what is the Department's proposal for allocating the
    requested funding for ex-offender activities? Please indicate which
    activities are new and what requested resources pay for continuation
    costs of current activities.
        Answer. The Department has not yet completed its review of current
    ex-offender projects, but plans to complete its review in the next few
    months. Following its completion, we will coordinate with the
    Department of Justice to develop a detailed plan for fiscal year 2010
    funding. As indicated in our congressional justification, we plan to
    continue funding both adult offender projects and youthful offender
    projects in fiscal year 2010. The Department is also considering a new
    grant competition to fund programs for juvenile offenders based on the
    civic justice corps model, which would offer youth paid opportunities
    for community service work along with intensive case management, life
    skills development, and job training.
                           transitional jobs programs
        Question. The budget proposes $50 million to demonstrate and
    evaluate transitional job program models and requests the authority to
    transfer some or all of these funds to the Departments of Health and
    Human Services and Justice. Transitional jobs programs have been
    supported in part by Temporary Assistance to Needy Families, Food
    Stamp, Employment and Training, Child Support Enforcement, WIA, youth
    programs, prisoner re-entry funds, and a variety of other city and
    State funds.
        Given that existing funding streams have supported and do support
    transitional jobs programs, what is gained by creating a new program to
    support transitional jobs? If there are limitations to the support for
    transitional jobs under existing programs, what changes in statute or
    regulation would need to be made to allow current funding streams/
    systems to more effectively support transitional jobs? What specific
    activities and corresponding dollar amounts would be involved in the
    requested transfer authority, if Congress were to appropriate funds as
    proposed in the budget request?
        Answer. The Department of Labor recognizes that other agencies have
    supported transitional jobs programs and that evaluations have shown
    this to be a promising intervention. In the program year 2010 budget,
    the Department is proposing to model how services and resources
    available through the workforce system can be utilized to increase
    workforce participation, primarily for noncustodial parents including
    young parents. The Department plans to work collaboratively with other
    agencies, particularly the Department of Health and Human Services, to
    implement a rigorous demonstration and evaluation to determine which
    program model or models have the greatest impact on participants'
    employment outcomes. A designated funding stream for transitional jobs
    is important so that the demonstration can be structured to provide
    evidence of program impacts that will be helpful to policymakers.
        The Department proposes using $50 million for this initiative from
    the Pilots, Demonstrations, and Research line item, as authorized by
    the WIA. The Department will use the majority of these funds for
    competitive grants to demonstrate new models and a smaller but
    significant portion to fund the evaluation.
          monitoring one-stop access by individuals with disabilities
        Question. Under work incentive grants which are proposed for
    elimination, the congressional budget justification states that ``ETA
    is monitoring One-Stop Career Centers to assess access by and services
    provided to individuals with disabilities''.
        How many monitoring visits or contacts have been conducted to date,
    and how many are planned for program years 2009 and 2010? What has this
    monitoring found on the issues of access and services for individuals
    with disabilities, including specifically physical and programmatic
    barriers?
        Answer. Part of the Employment and Training Administration's
    (ETA's) routine monitoring of grants, which includes Workforce
    Investment Act (WIA) and Employment Service funds, includes determining
    if grantees' locations and facilities are physically accessible and
    usable by disabled individuals. This monitoring is conducted throughout
    the country by staff in ETA's six regional offices. Monitoring is done
    using the ETA Core Monitoring Guide and ETA Grant Management Desk
    Reference as reference documents, and the monitoring is done both in
    the office (desk audits, review of submitted reports, and provision of
    technical assistance), and on-site, periodically. Any findings related
    to accessibility are resolved through ETA's usual process of follow-ups
    and technical assistance. Historically, this approach has been
    successful but in a case where access continues to be problematic ETA
    would consult with the Department's Civil Rights Center to identify a
    resolution.
        On-site monitoring visits are scheduled each fiscal year in a
    regional work plan, and the frequency of State visits is based, in
    part, on the availability of resources. Each State receives an in-
    person comprehensive review of all ETA programs every 3 years.
    Technical assistance is provided in response to requests, or in
    response to any identified deficiency in complying with Federal law or
    other program reporting or outcomes.
        In program year 2009, ETA monitored 25 States and plans to monitor
    23 States in program year 2010. A sample of local areas (at least two
    to three per State) are also reviewed in this process and visits to
    One-Stop Centers are made. ETA reviews 50-75 One-Stop Centers per year
    as part of this comprehensive review process. Accessibility is
    specifically evaluated on-site and any compliance problems would be
    documented in the review report prepared and submitted to the State.
    The regional office keeps all issues open until they are successfully
    resolved in accordance with Federal law and requirements.
        Additionally, Regional Offices also monitor discretionary grants
    such as the Disability Program Navigator (DPN). Ten DPN grants were
    monitored in program year 2009 and 16 DPN grants are slated to be
    reviewed in program year 2010. Any issues detected with accessibility
    through these reviews at the One-Stop Centers would also be identified.
        In program year 2010, ETA expects increased monitoring activity
    related to the Recovery Act. In preparation and as part of its
    technical assistance efforts related to implementation of the Recovery
    Act, ETA performed readiness assessments and consultations. Part of
    theses activities involved asking the States and territories if their
    One-Stops and all other service options were accessible to persons with
    disabilities. In response to this question, 51 of the 53 States/
    territories that responded stated that their One-Stops are accessible.
        Beyond the Federal monitoring activities discussed above, WIA
    nondiscrimination regulations require State and local area recipients
    of WIA funds to designate Equal Opportunity (EO) Officers. These WIA
    recipients and EO officers have an independent obligation to process
    complaints, monitor compliance with nondiscrimination laws, and ensure
    violations are remedied. The Department of Labor's Civil Rights Center
    provides training to these State and local EOs during annual
    development conferences held in the Washington, DC area and various
    States.
        Question. What actions has ETA taken or does it plan to take to
    address the documented fragmentation of services that has been found in
    a Government Accountability Office report?
        Answer. I believe the report you are referencing is the Government
    Accountability Office (GAO) report on Federal Disability Programs (GAO
    08-635) released in May 2008. This report found that individuals with
    disabilities often experience a fragmented Federal disability system.
    Although the report contained no specific recommendations for the
    Department of Labor, I agree that increased Federal coordination to
    better serve individuals with disabilities is extremely important and
    beneficial.
        The Disability Navigator Program has successfully served as the
    Department's model for addressing such fragmentation of services by
    helping One-Stop staff identify the full spectrum of available Federal,
    State, and local resources and services for persons with disabilities
    and the employers who hire them. Seven years of dedicated funding for
    this pilot program have successfully demonstrated this approach to
    support more integrated service provision for persons with
    disabilities, and ETA is now taking steps to ensure that States and
    localities continue this approach as part of their regular One-Stop
    Career Center activities.
        For fiscal year 2010, I have requested an increase of $10 million
    over fiscal year 2009 for the Office of Disability Employment Policy
    (ODEP). This increase will support a new initiative that builds upon
    the lessons learned by the Disability Navigators, and focuses on
    working with employers, the One-Stop system, labor-management
    organizations, and other stakeholders to vigorously promote the hiring,
    job placement and retention of individuals with disabilities,
    particularly youth, in integrated employment, apprenticeship, and pre-
    apprenticeship programs, and community service activities that help
    build skills for employment.
        In their report, GAO also recommended that all Federal stakeholders
    and Congress work together to construct a process for developing a
    cost-effective Federal strategy that would integrate services and
    support to individuals with disabilities. I look forward to future
    opportunities to work with Congress and other Federal agencies to
    consider steps to better coordinate and align services to individuals
    with disabilities.
        Question. The congressional budget justification also states that
    ``ETA expects to continue to see a significant increase in workforce
    service levels to job seekers with disabilities in the One-Stop Career
    Center system, even with termination of program funding.''
    Specifically, what actions does ETA intend to take to make this
    statement a reality?
        Answer. While the Department has recommended phasing out direct
    funding for this demonstration, it is actively working with States to
    utilize other Federal and State resources available to support the
    Navigator model, including Wagner-Peyser Act (Employment Service)
    funding, funding available for One Stop Career Centers to become
    Employment Networks under the Ticket to Work Program, and other
    sources. This administration remains strongly commitment to ensuring
    that individuals with disabilities receive the training and other
    support services that they need to obtain employment and succeed in the
    workplace. The Department recognizes that in an economic downturn and a
    tight labor market, individuals with more barriers to employment could
    be left behind. The Department is working to ensure all disadvantaged
    populations continue to have access to the resources of the public
    workforce system and benefit from the new infusion of resources
    provided by the American Recovery and Reinvestment Act. Some specific
    strategies include requiring States to specify how they will ensure
    disadvantaged populations continue to be a point of focus in
    modifications to their WIA and Wagner-Peyser Act State Plan that
    describe their Recovery Act strategies. In addition, we will provide
    ongoing technical assistance to the workforce system through webinars
    and other means and, in fact, have already produced a webinar with a
    focus on how to ensure individuals with disabilities are served with
    these new resources.
                     re-employment eligibility assessments
        Question. The 2010 budget request includes $50 million to continue
    support for Reemployment and Eligibility Assessments, an increase of
    $10 million over the fiscal year 2009 level. What is the current
    condition of State UI technology systems and how will these funds (and
    requested national activities funds) help improve improper payment
    prevention, detection and collection efforts?
        Answer. States' UI technology systems vary widely. However, we know
    that many State systems are 30 or more years old, use outdated
    technology, and have been difficult to modify to accommodate the
    Emergency Unemployment Compensation program, the Federal Additional
    Compensation program, and payment of Extended Benefits in States where
    that program has not triggered on since the early 1980s. These older
    systems have also had difficulty in quickly expanding capacity to the
    extent needed to process current workloads.
        The Department will use a portion of the requested funds to provide
    States the opportunity to implement technology-based systems that can
    help expand their capabilities to prevent, detect, and recover improper
    payments. Data matching systems, in particular, are a cost-effective
    method of preventing and detecting improper payments. These funds will
    allow States to enhance their current infrastructure and develop and
    implement new data matching systems to expand current capabilities.
        A few examples of such integrity-related systems include: (1) data
    matching systems, e.g., the National Directory of New Hires, among both
    Federal and State agencies, which help States to detect unreported
    earnings while an individual is filing for UI (the largest cause of
    improper UI payments) and help to detect other issues that may impact
    UI eligibility; and (2) internal data matching such as matching/
    analyzing transaction data for patterns that may indicate improper
    action by agency personnel. These new systems and system enhancements
    can make the States' integrity-related activities more accurate, cost
    effective, and expeditious.
        National Activities funds help States prevent, detect, and collect
    improper payments, primarily by supporting various activities, such as
    (1) the telecommunications network that links States with each other
    for data matching purposes as well interstate and combined wage claim
    processing; and (2) the use of new technology, such as the development
    and implementation of a State information data exchange system to
    support the electronic reporting of information from employers about
    why individuals no longer work for them, which is expected to improve
    the quality and timeliness of initial eligibility determinations based
    on the reason for an individual's job separation (incorrect initial
    eligibility determinations are the second largest cause of improper
    payments in the program).
                 administration of work opportunity tax credit
        Question. The 2010 budget request includes $18.52 million for
    administration of the work opportunity tax credit. The congressional
    budget justification notes that backlogs exist in a number of States.
        Is the requested amount sufficient to keep pace with the recent
    expansions of the program that have been enacted by Congress and
    eliminate current backlogs?
        Answer. The funding level has increased slightly, as shown in the
    table below. The Department will be monitoring the impact of the
    addition of two new target populations on workload.

                            [In thousands of dollars]
    ------------------------------------------------------------------------
                           Fiscal year                            Funding
    ------------------------------------------------------------------------
    2005....................................................          17,856
    2006....................................................          17,677
    2007....................................................          17,677
    2008....................................................          17,368
    2009....................................................          18,520
    ------------------------------------------------------------------------

        While the WOTC did not receive dedicated Recovery Act funds to
    assist with the new workload, States can choose to use Wagner-Peyser
    Recovery Act funds for this purpose, in addition to helping individuals
    find jobs and developing and delivering quality labor market and career
    guidance information.
        In the meantime, we are working with States with the highest
    backlogs to determine their key challenges and tailor technical
    assistance to those States to address their backlogs, including peer-
    to-peer technical assistance on automation strategies for States that
    have not automated their processes and help in addressing any
    challenges they face in getting necessary verification information from
    partner programs who have the necessary data.
        Question. What administrative actions and technical assistance will
    be provided to increase the timeliness of the certification process?
        Answer. As a result of backlogs in many States that resulted from a
    variety of administrative challenges, including lengthy hiatuses in the
    program, and as a result of the two newly added targeted populations,
    the Employment and Training Administration is currently undertaking a
    comprehensive program review, including assessments of the current
    costs to run the program; whether the funding formula utilized is the
    appropriate one; and whether the reporting and data collection
    processes ensure that we have the best information for monitoring the
    program.
        To support State implementation of the new Recovery Act provisions,
    in the immediate future we will conduct webinars on the new target
    groups authorized by the Recovery Act and the revised reporting forms
    for the program.
        Question. Could ETA establish systems that would allow employers to
    file the pre-screening IRS Form 8850 electronically?
        Answer. A number of States have improved electronic systems that
    allow for more automated, streamlined processing. Many of these States
    have indicated that processing times have been significantly reduced by
    eliminating data entry and other time-intensive manual processes.
    However, other States have indicated that more updated automation
    processes are needed. ETA will review this and determine whether
    Federal assistance in electronic filing is warranted.
                             wage and hour division
        Question. The budget request includes $240.960 million for
    enforcement of wage and hour standards, which is an increase of $30.862
    million and 288 Full Time Equivalents (FTE) over the 2009 level. What
    is the Department's plan (timeline and associated activities) for
    hiring these additional staff? How will the Department identify the
    geographic areas and industries in which to deploy these additional
    staff? How are community resources and community-based organizations
    engaged by the Wage and Hour Division (WHD) to ensure that workers are
    paid wages due them? What actions is WHD taking or planning this year
    and in 2010 to strengthen enforcement of the 14(c) provision of the
    Fair Labor Standards Act? What is the amount of resources dedicated to
    14(c) enforcement in the current year and planned for 2010?
        Answer. The WHD enacted fiscal year 2009 budget represents a
    $17,434,000 increase over the fiscal year 2008 enacted level and
    increases the agency's FTE ceiling from 1,208 in fiscal year 2008 to
    1,283 in fiscal year 2009. In order to reach the 1,283 FTE ceiling for
    fiscal year 2009, WHD is hiring 170 new staff which includes 162 new
    investigators. These new hires should be on-board before the end of
    fiscal year 2009.
        A number of key factors were used to determine how to allocate
    these additional staff among WHD's five regions. Those criteria
    included:
      --The rate of attrition over the last 8 years;
      --The percent of directed investigations in low-wage industries;
      --The percent of total incoming complaints;
      --The percent of low-wage minimum wage violations;
      --The percent of low-wage overtime wage violations; and
      --The strength of State laws and State law enforcement.
        In addition, WHD is now hiring an additional 116 staff, 100 of
    which will be investigators, to ensure that contractors performing work
    on American Recovery and Reinvestment Act (ARRA) projects are in
    compliance with the applicable prevailing wage laws. WHD will use
    trained and experienced investigators for ARRA-related enforcement and
    compliance assistance and will charge their related costs to the ARRA
    funding. This, in turn, will allow WHD to finance the 100 new
    investigator positions. These new investigators are allocated to WHD
    offices by State in proportion to the number of estimated jobs created
    and/or saved by ARRA funding. We expect these new hires to be on-board
    no later than mid-September 2009.
        The President's fiscal year 2010 request includes an increase of
    $30,862,000 and 288 FTE, the large majority of which will be
    investigators. The requested FTE ceiling is 1,571. Given the ongoing
    fiscal year 2009 and ARRA hiring, WHD will be close to the fiscal year
    2010 ceiling early in the fiscal year. If the fiscal year 2010
    requested FTE ceiling is not enacted, WHD will slow attrition hiring to
    ensure that it stays within fiscal year 2010 FTE ceiling. The fiscal
    year 2010 requested increase in FTEs will bring WHD back to pre-fiscal
    year 2001 investigator staffing levels. WHD will use the same criteria
    in fiscal year 2010 as it uses in fiscal year 2009 to allocate
    additional staff in the five WHD regions.
        The President's request also includes resources to help WHD
    continue the revival of customer service by supporting improved
    complaint intake and more in-depth complaint investigation processes
    and resources to strengthen enforcement on behalf of vulnerable
    workers. If enacted, the budget will allow WHD to increase its
    coordination with stakeholders such as community organizations and
    employ other strategies that will improve its customer service.
        WHD has spent investigative, administrative, training, and
    educational resources over the last several years in an effort to
    increase employer compliance with the Fair Labor Standards Act (FLSA)
    section 14(c) program. Section 14(c) certified employers represent less
    than 0.07 percent of the approximately 7 million FLSA covered
    workplaces in the United States.; however, they represent 0.56 percent
    of WHD investigations of employers conducted each year and 2.17 percent
    of all directed or noncomplaint based investigations conducted each
    year. Over the last several years, WHD's regional and district offices
    have developed enforcement and education initiatives to promote
    compliance with this program within their respective geographic areas.
    On average over the last 5 years, WHD has conducted more than 180
    section 14(c) investigations. Those efforts will continue in fiscal
    year 2010 as WHD plans to repeat the investigation-based compliance
    survey of section 14(c)-certified employers to determine if compliance
    among section 14(c)-certified employers has improved over the 2002
    levels.
                   national emphasis program on recordkeeping
        Question. The 2009 appropriations act included additional funds for
    OSHA to explore and address an apparent lack of completeness of the
    OSHA Log of Work-related Injuries and Illnesses. The congressional
    budget justification indicates that a National Enforcement Program
    (NEP) on Recordkeeping is currently under development. When will this
    NEP be issued and implemented, and how will these additional funds be
    utilized? How much funding is included in the 2010 budget request to
    continue this work or initiate additional activities? What activities
    will this funding support?
        Answer. The NEP is currently under National Council of Field Labor
    Locals (NCFLL) review, generally the final step in the review of NEPs
    before implementation, and is expected to be in place by August 1,
    2009. The NEP is designed to identify underrecorded and misrecorded
    injuries and illnesses in selected establishments, and to enforce the
    agency's recordkeeping requirements. The Bureau of Labor Statistics,
    which is producing its own report on the potential underreporting of
    injuries and illnesses, was consulted during the drafting of the NEP.
        In fiscal year 2009, OSHA will dedicate the $1,000,000 provided in
    the agency's appropriation to improve recordkeeping enforcement.
    Beginning in fiscal year 2009, OSHA plans to conduct at least 350
    programmed inspections over the course of the NEP--a significant
    increase over historical inspection totals--to investigate the accuracy
    of the information employers are required to record on the OSHA 300
    log. The agency will issue citations and penalties, as appropriate, for
    recordkeeping violations found as a result of the inspections conducted
    under this NEP in fiscal year 2009 and future years. The NEP will
    target establishments that operate in historically high injury and
    illness rate industries, as identified by the Bureau of Labor
    Statistics, but have reported low rates of injuries and illnesses. The
    program will also include establishments in the construction and
    poultry processing industries, due to the inherently high-hazard nature
    of the work in those industries, and due to questions that have been
    raised regarding recordkeeping practices in those industries.
        Assessments of the accuracy of establishment-specific recordkeeping
    data will include interviews with employers, employees, company
    recordkeepers, first-aid providers, and healthcare providers; the
    assessment will also include a review of relevant records and
    documentation, such as medical records, workers' compensation records
    and first-aid records.
        As part of this initiative, OSHA will also provide more intensive
    training to its Compliance Safety and Health Officers (CSHOs) on
    identifying potential problems in recordkeeping data and systems
    through a mandatory course on recordkeeping. The agency's Training
    Institute staff are beginning to revise the core curriculum for CSHOs
    to include a week-long rigorous training course. The agency will direct
    necessary resources for inspections and to fully train its compliance
    staff in fiscal year 2010.
        OSHA will also evaluate the NEP to determine what steps or measures
    and additional resources, if any, are needed to improve recordkeeping.
                                 hiring at osha
        Question. The budget request includes $19.569 million for safety
    and health standards, which is an increase of $2.365 million and 20 FTE
    over the 2009 level. What is the Department's plan (timeline and
    associated activities) for hiring these additional staff?
        Answer. The agency will build on its aggressive hiring efforts in
    fiscal year 2009 to jumpstart the hiring of positions in fiscal year
    2010, and is ready to move on the first day that fiscal year 2010
    appropriated funds are available to begin filling all additional
    standards positions. The agency has historically realized significant
    interest from highly qualified applicants for employment opportunities
    for these positions, which has also been evident in the current fiscal
    year. In terms of recruitment and hiring, the agency is prepared to
    fill vacant positions with the aid of announcements that are published
    in various trade journals and other professional publications, as
    appropriate, and is working with the Department's Civil Rights Center
    to identify other venues where potential applicants may be present.
    Announcements are also strategically shared with the various colleges,
    universities, and professional associations whose students and members
    have the desired skills and abilities for the specific positions. OSHA
    will also make use of various human resource authorities and
    strategies, such as recruitment bonuses and student loan repayment, as
    appropriate, to meet hiring needs.
        Question. The budget request includes $227.149 million for Federal
    enforcement, which is an increase of $29.203 million and 160 FTE over
    the 2009 level. What is the Department's plan (timeline and associated
    activities) for hiring these additional staff?
        Answer. OSHA plans to build on fiscal year 2009 and Recovery Act
    hiring to jump-start the hiring of fiscal year 2010 enforcement
    personnel. The agency is ready to move on the first day that fiscal
    year 2010 appropriated funds are available to begin filling all
    additional enforcement positions. The majority of these FTE are
    compliance safety and health officer positions distributed across
    OSHA's 10 regional offices through assessing need by the injury and
    illness rates of industry sectors and number of covered establishments
    in those sectors. The agency will make full use of various human
    resource tools, including Federal Career Intern appointments,
    recruitment bonuses and student loan repayment, as appropriate, and
    work with professional organizations, colleges and universities to
    reach interested and qualified candidates. In addition, the agency
    plans to seek qualified candidates for enforcement positions that will
    address the increasing need for bilingual language skills by
    participating in job fairs and utilizing OSHA information booths to
    promote job opportunities in the agency.
                      severe violators enforcement program
        Question. In March of this year, the Office of Inspector General
    (IG) issued an audit that raised several issues with the Enhanced
    Enforcement Program (EEP). Is the Severe Violators Inspection Program a
    replacement for the EEP? If so, how will this new program incorporate
    the best of the EEP as well as the IG findings into account in
    designing this new program? How will this request enable OSHA to move
    forward on ergonomics-related enforcement activities?
        Answer. OSHA's EEP will be replaced with a new program that is now
    tentatively called the Severe Violators Enforcement Program (SVEP). The
    agency has created a task force composed of regional administrators,
    two deputy regional administrators, Department of Labor attorneys, and
    OSHA's Directorate of Enforcement Programs staff, among others. The
    task force met in May 2009 to begin designing a new program to address
    certain employers and known, often-found hazards. The task force will
    continue to work on creating the SVEP and determining how to implement
    the program. OSHA expects to issue a field directive for the new
    program by the end of this summer.
        The SVEP will not be especially linked to ergonomics-related
    enforcement activities, except in instances in which employers with
    ergonomic hazards at their worksites are identified through the Task
    Force's criteria.
                 survey of occupational injuries and illnesses
        Question. The 2009 appropriations act included additional funds for
    Bureau of Labor Statistics (BLS) to explore and address a potential
    undercount of injury and illness data.
        How much funding is included in the 2010 budget request for BLS to
    continue this work or initiate additional activities? What activities
    will this funding support?
        Answer. The 2010 request includes $1.3 million for the continuation
    of activities regarding a potential Survey of Occupational Injuries and
    Illnesses (SOII) undercount in three areas: matching research, employer
    interviews, and a multiple data source pilot. Results for all three of
    these activities, begun in 2009, will be ready by 2012 with interim
    results available on some topics earlier.
      --Matching Research.--This work includes matching SOII data with
            workers' compensation data to understand what types of workers'
            compensation cases do not appear in BLS data. Most of the
            matching will take place in 2010 and early 2011, with BLS and
            the States conducting further research into the types of
            injuries and illnesses that are in the workers' compensation
            records, but not in the SOII, beginning in 2010.
      --Employer Interviews.--Sampled employers will be interviewed about
            factors that affect recording cases on OSHA logs and the filing
            of workers' compensation claims. The interviews will focus on
            certain areas where recordkeeping might be difficult or
            unclear. Establishments will be selected for interview (partly
            based on the results of the matching research described above)
            in 2010 and 2011.
      --Multiple Data-source Pilot.--BLS plans to work with a small number
            of State partners to pilot the use of multiple data sources to
            enumerate two types of injuries: workplace amputations and
            carpal tunnel syndrome cases that, unlike amputations, are less
            clearly linked to the workplace. The data gathering and
            analysis will begin in 2010 and extend through 2011.
        For additional information on these topics, please see the recently
    submitted letter report.
                         program direction and support
        Question. The budget increase includes $34.125 million for program
    direction and support (PDS), an increase of $11.294 million over the
    2009 level. This increase includes $2.35 million for the Office of the
    Recovery for Auto Communities and Workers. How much is being spent for
    the Office in 2009 and from what funding source? Please identify the
    PDS offices that will be supported with the balance of increased funds
    in 2010 and explain why such a large increase is needed.
        Answer. The Office of the Recovery for Auto Communities and Workers
    budget for fiscal year 2009 is budgeted at $710,000 and eight staff.
    Because of the severe constraints facing the PDS activity in fiscal
    year 2009, this fiscal year, we are sending an addendum to the American
    Recovery and Reinvestment Act Operating Plan to use funds appropriated
    to Departmental Management (DM) under Public Law 111-8. This program
    will be entirely funded from Recovery Act dollars in fiscal year 2009.
        In fiscal year 2010, $2.35 million is requested to annualize
    operations begun in fiscal year 2009 as well as expand the program to
    meet anticipated needs of this industry and associated community
    impacts. The balance of the increase is associated with restoring the
    PDS activity back to the basic level of funding needed for each office
    that is funded through this activity (i.e., the immediate Office of the
    Secretary, Office of the Deputy Secretary, Office of Congressional and
    Intergovernmental Affairs, Office of Public Affairs, Office of the
    Assistant Secretary for Policy, Office of Public Liaison, Office of
    Faith-Based Programs, and Office of Small Business Programs).
        In fiscal year 2008, Congress enacted a $5.3 million (18.7 percent)
    reduction to the PDS budget activity, compared to the fiscal year 2007
    funding level. To partially restore funding and provide for adequate
    policy direction, the Department reprogrammed $3.506 million from other
    DM budget activities. In fiscal year 2009, Congress enacted a budget
    for PDS equal to the fiscal year 2008 level. The fiscal year 2009
    enacted funding level for DM PDS represents the lowest level of funding
    for this activity since 1999. Adjusted for inflation, the enacted level
    is the lowest level ever for PDS going back to fiscal year 2003. To
    address this problem in fiscal year 2009, the Department is executing a
    reprogramming within the DM account to shift $3 million to the PDS
    activity.
        Historically, PDS funding supports 130-150 FTE. While this level
    has varied from year-to-year since fiscal year 1993, the fiscal year
    2010 President's budget request supports this historical trend by
    including 152 FTE for this budget activity.
                            office of the solicitor
        Question. Please provide a breakdown of legal services workloads by
    office, as well as the 2009 and 2010 request Office of the Solicitor
    (SOL) staffing levels by office. At the 2010 request level for the SOL,
    matters pending under both the litigation and opinion/advice workload
    increase over the 2009 level. Why, and what is the impact of these
    pending levels?
        Answer. Legal Services Workloads by SOL Office.--Submitted with
    this response is the breakdown of the entire legal services workload
    for all clients by each SOL division, region, and subregional office
    for the period from fiscal year 2005 through May 31, 2009, as reflected
    in the hours recorded by attorneys and paralegals. These figures do not
    include senior managers and administrative support staff, who do not
    record work hours in the SOL time distribution system. Also, included
    is a tabulation of the number of Mine Safety and Health Administration
    (MSHA) cases received by SOL's various regions and divisions and hours
    recorded by attorneys and paralegals on MSHA matters during fiscal year
    2008 and the first two quarters of fiscal year 2009.

                                                                                           LITIGATION MATTERS
    ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                    Received                                          Concluded                                          Pending
                                               -----------------------------------------------------------------------------------------------------------------------------------------------------
                      Office                     Fiscal    Fiscal    Fiscal    Fiscal    Fiscal    Fiscal    Fiscal    Fiscal    Fiscal    Fiscal    Fiscal    Fiscal    Fiscal    Fiscal    Fiscal
                                                  year      year      year      year      year      year      year      year      year      year      year      year      year      year      year
                                                  2005      2006      2007      2008    2009 \1\    2005      2006      2007      2008    2009 \1\    2005      2006      2007      2008    2009 \1\
    ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
    ARLINGTON.................................       971     1,687     1,151     1,764       822     1,131     1,012     1,314     1,060       659     1,134     1,920     1,675     2,387     2,668
    ATLANTA...................................     1,013       986       818     1,330       649     1,101     1,080     1,000       913       545       781       766       680     1,124     1,232
    BLLLS.....................................     1,018       931     1,316       873       623     1,167     1,000     1,178     1,206       643       867       800     1,061       722       770
    BOSTON....................................       604       548       709       677       351       858       564       523       720       400       670       679       891       833       800
    CHICAGO...................................     1,066     1,110       900     1,102       545     1,077     1,105       808       902       663       746       569       694       813       772
    CLEVELAND.................................       766       642       526       523       352       853       728       507       607       316       400       357       407       317       352
    CRLM......................................       193       150       117       142       107       308       254       147       144        95       236       134       130       120       127
    DALLAS....................................     1,236     1,034     1,062     1,181       730     1,248     1,068     1,014     1,025       865       725       736       741       786       719
    DENVER....................................       493       506       457       887       310       421       500       355       759       342       368       376       510       619       613
    ETLS......................................       367       202       272       444       446       301       410       742       345       346       902       622       210       270       359
    FEEWC.....................................       277       301       306       222       159       246       313       337       225       137       510       491       344       269       280
    FLS.......................................        88        94        56        47        22        41        92        40        47        12       254       185       217       205       189
    HONORS....................................        72        43        52        41        54        18  ........       200  ........  ........       236       269       126       162       216
    KANSAS CITY...............................       692       621       540       887       419       636       716       549       535       475       420       275       310       712       601
    LOS ANGELES...............................       462       411       328       422       149       420       431       375       271       161       233     2,895       197       319       301
    MALS......................................        68       200       107        37        37        97       187       150       105        20       200       170       129       108        77
    MSH.......................................       370       285       240       319       163       190       214       476       395       205       524       593       363       190       224
    NASHVILLE.................................     1,375     1,514     1,412     2,020     1,008     2,855     1,853     1,787     1,583       966     1,943     2,069     2,111     2,533     2,764
    NEW YORK..................................     1,090     1,170       894     1,061       743     1,097     1,172     1,096     1,023       790       631       674       572       592       595
    OLC.......................................         6  ........  ........  ........  ........        27  ........       100  ........  ........       102       102         1         1         1
    OSH.......................................       105       167       191       167        62       115        77       178       171        17        80       181       186       131       172
    PBSD......................................       322       413       270       119       123       348       506       104       317       161       480       375       449       221       170
    PHILADELPHIA..............................     1,168     1,129     1,074     1,567       821     1,055     1,035     1,145     1,138       815       725       803       731     1,117     1,057
    SAN FRANCISCO.............................       643       722       643       755       338       591       754       539       698       334       384       328       488       530       553
    SEATTLE...................................       419       355       312       472       210       440       424       289       318       242       221       180       253       357       351
                                               -----------------------------------------------------------------------------------------------------------------------------------------------------
          TOTAL...............................    14,884    15,221    13,753    17,059     9,243    16,641    15,495    14,953    14,507     9,209    13,772    16,549    13,476    15,438    15,963
    ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
    \1\ Fiscal year 2009 actuals through 5/31/09.

    Note: Litigation.--The process of resolving legal controversies through a court of law or adjudicative administrative board.
        Matter.--Something for which the receiving office has demonstrated responsibility (i.e., is authorized to take action) for providing legal services and which is referred from any source
      for possible action.

                                                                                         OPINION/ADVICE MATTERS
    ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                    Received                                          Concluded                                          Pending
                                               -----------------------------------------------------------------------------------------------------------------------------------------------------
                      Office                     Fiscal    Fiscal    Fiscal    Fiscal    Fiscal    Fiscal    Fiscal    Fiscal    Fiscal    Fiscal    Fiscal    Fiscal    Fiscal    Fiscal    Fiscal
                                                  year      year      year      year      year      year      year      year      year      year      year      year      year      year      year
                                                  2005      2006      2007      2008    2009 \1\    2005      2006      2007      2008    2009 \1\    2005      2006      2007      2008    2009 \1\
    ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
    ARLINGTON.................................        19        24        11         7        20        15        24        16         6        13         7         9         6         6        14
    ATLANTA...................................       354       337       238       150        66       310       359       271       184        57       135       113        99        54        54
    BLLLS.....................................        35         5        19        43        43        11        14        16        29        23       113        53        22        37        51
    BOSTON....................................        80        70        49        68        33        84        96        40        85        41        74        49        65        47        43
    CHICAGO...................................       195       259       137       163       137       171       259       208       159       125       110        91        29        22        37
    CLEVELAND.................................        34        31        38        29         9        37        45        31        35        11        14         3        18        11         5
    CRLM......................................       751       486       483       479       330       695       668       502       470       286       301       103       118       157       132
    DALLAS....................................       245       125        92       154       100       232       123        92       161       103        73        69        64        32        30
    DENVER....................................        34        10       114       118        77        39        14        91       116        72        18        16        53        66        51
    ETLS......................................       808       658       542       656       526       545       861       859       688       374       708       548       295       259       346
    FEEWC.....................................       468       393       643       590       328       419       393       670       576       214       190       134       181       132       206
    FLS.......................................       914       793       654       668       310       633       785       693       570       189     1,036       565       638       732       723
    HONORS....................................        96        14        16        14        28        15  ........       578  ........  ........       641       605        44        57        87
    KANSAS CITY...............................       194       282       211       188       133       128       301       193       147        83       124        65        95       184       182
    LOS ANGELES...............................         4         5         5         5         4         5         4         6         5         2         1       120         3  ........         2
    MALS......................................       782       802     1,250     1,378       880       355       837     2,284     1,374       367     2,124     2,068     1,079     1,566      1533
    MSH.......................................       278       258       351       388       343       245        60     1,245       483       208     1,146     1,344       438       357       454
    NASHVILLE.................................        92       121        91       103        64        68        86       117        82        53        44        74        62        63        78
    NEW YORK..................................        91       150        99       135        85        56       132       104        94        92        62        66        52       121        72
    OLC.......................................       610       644       683       764       272        85         4     9,541       192       102     9,011     9,653       814     1,376      1531
    OSH.......................................     1,484     1,228     1,088     1,168       739     1,295       950     1,120     1,321       509       436       674       445       219       432
    PBSD......................................       515       473       543       549       385       502       502       612       658       311       112        59       105       103       186
    PHILADELPHIA..............................        77        78        85        63        53        75        86        86        63        56        22        12        23        25        11
    SAN FRANCISCO.............................       110       163       103        84        64       119       138        99        70        59        34        41        43        56        65
    SEATTLE...................................        14        46        29        16        10        15        41        29        11        16         2         6         5         9         5
                                               -----------------------------------------------------------------------------------------------------------------------------------------------------
          TOTAL...............................     8,284     7,455     7,574     7,980     5,039     6,154     6,782    19,503     7,579     3,366    16,538    16,540     4,796     5,691     6,330
    ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
    \1\ Fiscal year 2009 actuals through 5/31/09.

    Note: Opinion.--The interpretations of law and regulations that SOL attorneys are requested to provide.
        Advice.--A request (oral or written) for information from the general public or client agency relating to a specific matter of law.
        Matter.--Something for which the receiving office has demonstrated responsibility (i.e., is authorized to take action) for providing legal services and which is referred from any source
      for possible action.

                                                                                           REGULATION MATTERS
    ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                    Received                                          Concluded                                          Pending
                                               -----------------------------------------------------------------------------------------------------------------------------------------------------
                      Office                     Fiscal    Fiscal    Fiscal    Fiscal    Fiscal    Fiscal    Fiscal    Fiscal    Fiscal    Fiscal    Fiscal    Fiscal    Fiscal    Fiscal    Fiscal
                                                  year      year      year      year      year      year      year      year      year      year      year      year      year      year      year
                                                  2005      2006      2007      2008    2009 \1\    2005      2006      2007      2008    2009 \1\    2005      2006      2007      2008    2009 \1\
    ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
    ARLINGTON.................................  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........
    ATLANTA...................................  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........
    BLLLS.....................................         3         1  ........         1         1         1         3  ........         1  ........         5         2         1         1         2
    BOSTON....................................  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........
    CHICAGO...................................  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........
    CLEVELAND.................................  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........
    CRLM......................................        10        11         9         5  ........        14        15         7         8         1         8         5         6         3         1
    DALLAS....................................  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........
    DENVER....................................  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........
    ETLS......................................        10         7         9         8        12         1        16        16        12         9        34        25        17        14        17
    FEEWC.....................................         2         2  ........         3  ........         3         2         1  ........  ........         1         1         4         2         3
    FLS.......................................         4         6         2         6         5         4         3         8         1         2        16        14        11        12        16
    HONORS....................................         9         9         2         5         2         2  ........        18  ........  ........        18        27        11        16        18
    KANSAS CITY...............................  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........
    LOS ANGELES...............................  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........
    MALS......................................         4  ........  ........         1  ........         1  ........        20         3  ........        23        23         2         3  ........
    MSH.......................................        15        10        13        12         7         6  ........        41        17        21        55        65        39        36        16
    NASHVILLE.................................  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........
    NEW YORK..................................  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........
    OLC.......................................         1  ........  ........  ........  ........  ........  ........         6  ........  ........         6         6  ........  ........  ........
    OSH.......................................        30        16        13        46        33        44        21        21        46        13        52        42        30        30        51
    PBSD......................................        43        41        44        39         5        40        35        51        33         6        24        27        27        26        22
    PHILADELPHIA..............................  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........
    SAN FRANCISCO.............................  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........
    SEATTLE...................................  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........  ........
                                               -----------------------------------------------------------------------------------------------------------------------------------------------------
          TOTAL...............................       131       103        92       126        65       116        95       189       121        52       242       237       148       143       146
    ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
    \1\ Fiscal year 2009 actuals through 5/31/09.

    Note: Regulation.--All workload matters that are related to the development and promulgation of regulations and standards.
        Matter.--Something for which the receiving office has demonstrated responsibility (i.e., is authorized to take action) for providing legal services and which is referred from any source
      for possible action.

                                                                   CLIENT MSHA CASES RECEIVED
    --------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                   Fiscal year 2008                                Fiscal year 2009
                                                             -----------------------------------------------------------------------------------------------
                             Office                                                                                                                 Fiscal
                                                                  Q1          Q2          Q3          Q4        Fiscal        Q1          Q2        year to
                                                                                                              year total                             date
    --------------------------------------------------------------------------------------------------------------------------------------------------------
    ARLINGTON...............................................         275         275         375         364       1,289         244         142         386
    ATLANTA.................................................          67         201         145         138         551          67          56         123
    BOSTON..................................................          12          27          49          22         110           8  ..........           8
    CHICAGO.................................................          63         102         149         104         418          85          59         144
    CLEVELAND...............................................  ..........           7          25          20          52          11          10          21
    DALLAS..................................................          52          75          85          93         305          44          30          74
    DENVER..................................................         172         262         196         206         836         122          56         178
    FEEWC...................................................           4           2           1           1           8           2  ..........           2
    HONORS..................................................  ..........  ..........  ..........  ..........  ..........  ..........          22          22
    KANSAS CITY.............................................          11          93         166          39         309          38          13          51
    LOS ANGELES.............................................          15         116          23          23         177          14          12          26
    MALS....................................................          12          22          25          13          72          17           8          25
    MSH.....................................................         153         162         196         213         724         222         173         395
    NASHVILLE...............................................         323         376         352         363        1414         325         268         593
    NEW YORK................................................          16          20          21          18          75           7           4          11
    OSH.....................................................  ..........  ..........  ..........  ..........  ..........           1  ..........           1
    PHILADELPHIA............................................         127         161         321         229         838         200          77         277
    SAN FRANCISCO...........................................          57          61          84          65         267          39          17          56
    SEATTLE.................................................          64          40          50          73         227          18          23          41
                                                             -----------------------------------------------------------------------------------------------
          GRAND TOTAL.......................................       1,423       2,002       2,263       1,984       7,672       1,464         970       2,434
    --------------------------------------------------------------------------------------------------------------------------------------------------------

                                                                                        CLIENT MSHA HOURS CHARGED
    ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                                     Fiscal year 2008                                                Fiscal year 2009
                                                                     -------------------------------------------------------------------------------------------------------------------------------
                                 Office                                                                                                                                               Fiscal year to
                                                                            Q1              Q2              Q3              Q4             Total            Q1              Q2             date
    ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
    ARLINGTON.......................................................        2,476.75        2,878.00        2,937.00        3,272.50       11,564.25        2,708.50        2,804.25        5,512.75
    ATLANTA.........................................................          835.50          847.50          880.75        1,111.00        3,674.75        1,004.50          797.75        1,802.25
    BLLLS...........................................................  ..............  ..............             .50  ..............             .50  ..............  ..............  ..............
    BOSTON..........................................................          432.00          385.50          418.00          702.75        1,938.25          485.25          510.50          995.75
    CHICAGO.........................................................        1,343.25        1,692.00        1,894.50        2,438.50        7,368.25        1,674.50        1,674.50        3,349.00
    CLEVELAND.......................................................  ..............           79.00          220.50          297.50          597.00          286.25          290.25          576.50
    CRLM............................................................  ..............            1.00  ..............  ..............            1.00  ..............  ..............  ..............
    DALLAS..........................................................          978.00          819.75        1,257.50        1,171.50        4,226.75          857.75        1,041.50        1,899.25
    DENVER..........................................................        1,498.75        1,947.25        1,728.00        2,108.75        7,282.75        1,886.50        1,814.25        3,700.75
    ETLS............................................................  ..............  ..............  ..............            6.75            6.75  ..............  ..............  ..............
    FEEWC...........................................................           80.75           97.50          202.75           47.25          428.25          237.50          263.75          501.25
    FO..............................................................             .50  ..............            3.50            4.75            8.75           42.00  ..............           42.00
    HONORS..........................................................             .50  ..............  ..............  ..............             .50           63.75          468.50          532.25
    KANSAS CITY.....................................................          332.75          438.25          797.50          817.50        2,386.00          688.25          847.75        1,536.00
    LOS ANGELES.....................................................          174.00          234.50          407.50          387.25        1,203.25          290.75          309.25          600.00
    MALS............................................................          160.25          195.75          251.25          153.25          760.50          570.75          755.25        1,326.00
    MSH.............................................................        7,752.50        8,627.75        9,189.25        9,457.25       35,026.75        8,265.75        8,256.25       16,522.00
    NASHVILLE.......................................................        2,816.25        3,742.00        3,146.25        3,286.25       12,990.75        3,513.75        2,985.50        6,499.25
    NEW YORK........................................................          220.50          237.00          265.25          345.25        1,068.00          217.25           84.75          302.00
    OSH.............................................................             .00             .00            1.00             .00            1.00             .25             .00             .25
    PBS.............................................................           40.00  ..............  ..............  ..............           40.00  ..............  ..............  ..............
    PHILADELPHIA....................................................        2,602.50        3,575.50        4,286.25        4,081.00       14,545.25        3,603.00        4,526.25        8,129.25
    SAN FRANCISCO...................................................        1,170.25        1,035.25        1,117.25        1,132.00        4,454.75        1,005.75          925.50        1,931.25
    SEATTLE.........................................................          400.25          426.50          792.50          616.00        2,235.25          415.25          303.75          719.00
                                                                     -------------------------------------------------------------------------------------------------------------------------------
          GRAND TOTAL...............................................       23,315.25       27,260.00       29,797.00       31,437.00      111,809.25       27,817.25       28,659.50      56,476.755
    ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

        Fiscal Year 2009 and Fiscal Year 2010 Staffing Levels by SOL
    Office.--SOL is increasing its appropriated FTE level to a projected
    maximum of approximately 646 FTE by the end of fiscal year 2009, and
    further increasing to approximately 679 FTE during fiscal year 2010.
    These additional FTE are almost entirely attorneys and legal support
    staff dedicated to supporting the enforcement and other legal services
    required by the Department. SOL's fiscal year 2009 appropriation has
    enabled the agency to continue to pay for 22 additional FTE that were
    added in fiscal year 2007 and fiscal year 2008 in response to the
    dramatic increase in MSHA-related matters being received by SOL. As the
    result of an memorandum of understanding signed in October 2008 between
    MSHA and SOL, the level of SOL's MSHA caseload is stabilizing. This
    stabilization is enabling SOL's regions to provide more attention to
    MSHA's most important cases and needed legal enforcement support and
    other services to OSHA, EBSA, WHD, OFCCP, and other DOL agencies.
        The current intention is that SOL's FTE complement will be
    assigned, as follows. The fiscal year 2010 assignments are tentative,
    and subject to further review.

    ----------------------------------------------------------------------------------------------------------------
                                                                        Fiscal year     Fiscal year     Fiscal year
                               SOL offices                                 2008            2009            2010
    ----------------------------------------------------------------------------------------------------------------
    Immediate office................................................  ..............              10               8
        Office of Legal Counsel.....................................  ..............              13              13
        Honors program..............................................  ..............               7              15
    National office divisions:
        Management and Administrative Legal Services................  ..............              57              60
        Black Lung Longshore Legal Services.........................  ..............              29              30
        Civil Rights and Labor-Management...........................  ..............              33              34
        Employment Training Legal Services..........................  ..............              25              26
        Fair Labor Standards........................................              21              25              26
        Federal Employees' and Energy Workers' Compensation.........  ..............              13              14
        Mine Safety and Health......................................              31              31              31
        Occupational Safety and Health..............................              33              36              37
        Plan benefits security......................................              35              40              42
    Regions:
        Region 1--Boston............................................  ..............              28              29
        Region 2--New York..........................................  ..............              37              39
        Region 3--Philadelphia......................................  ..............              53              56
        Region 4--Atlanta...........................................  ..............              53              57
        Region 5--Chicago...........................................  ..............              47              48
        Region 6--Dallas............................................              33              36
        Region 7--Kansas City.......................................  ..............              38              39
        Region 8--San Francisco.....................................  ..............              38              39
    ----------------------------------------------------------------------------------------------------------------
    Note. Most of the enforcement and other litigation that supports ESA and OSHA takes place in the SOL regional
      offices.

        Matters Pending.--The short answer to the query regarding the
    reason for, and impact of the continuing increases in ``matters
    pending'' projected for the end of fiscal year 2009 and of fiscal year
    2010 is that although SOL expects to be able to conclude more matters
    during the same periods as the result of additional FTE, the number of
    ``matters pending'' is projected to increase at an even greater rate.
        The impact is that SOL will continue to have to take action in
    those matters that more directly impact the strategies and goals of the
    Secretary and client agencies, and not attend to all pending matters. A
    more detailed explanation follows:
        The category of ``matters pending'' represents the actual or
    projected number of legal matters that are pending in SOL at the end of
    a fiscal year. SOL calculates this workload statistic in each of the
    three primary categories of work that the agency performs: litigation,
    opinion/advice, and regulatory work. During the past several fiscal
    years (fiscal year 2007 and fiscal year 2008), SOL has experienced an
    actual increase in the number of pending matters in all three
    categories, as follows:

    ----------------------------------------------------------------------------------------------------------------
                                                        Fiscal year     Fiscal year     Fiscal year     Fiscal year
                     Matters pending                       2007            2008            2009            2010
    ----------------------------------------------------------------------------------------------------------------
    Litigation......................................          12,826          17,200          19,949          22,468
    Opinions/advice.................................           3,948           4,737           5,175           5,518
    Regulations.....................................             128             150             157             144
    ----------------------------------------------------------------------------------------------------------------

        The ``matters pending'' category for any given fiscal year results
    from adding the total number of ``matters pending'' at the end of the
    prior fiscal year, plus the total ``matters received'' during the
    fiscal year, and then subtracting from that number the total ``matters
    concluded'' by SOL during the fiscal year.
        Because SOL has experienced a growth in overall workload over the
    past several years, and because of increases in enforcement-related FTE
    in SOL's client agencies, as well as worker protection law enforcement
    activity, SOL initially projects continuing increases in this workload
    statistic for fiscal year 2009 and fiscal year 2010. The magnitude of
    the projected increases in this statistic have, however, been
    significantly influenced by another factor: the increase in SOL FTE
    during fiscal year 2009 from a current level of about 610 to
    approximately 646 by the end of this fiscal year; and an additional
    increase to approximately 679 FTE by the end of fiscal year 2010.
        Because of these projected FTE increases, using fiscal year 2008
    actual ``matters concluded'' as a base, SOL also projects that it will
    be able to conclude an additional 906 matters in fiscal year 2009, and
    an additional 3,299 matters in fiscal year 2010. While an inflexible
    correlation between output and numbers of FTE is not possible, due to
    the wide variation in the size and complexity of legal matters and the
    varying arrival dates of new FTE, this overall 12 percent increase in
    output between fiscal year 2008 and fiscal year 2010 corresponds with
    the 11 percent increase in FTE from the current level of about 610 to
    the projected level of 679 in fiscal year 2010. This increase in SOL's
    capacity to conclude matters has lowered the projected increase in
    ``matters pending'' at the end of fiscal year 2009 and fiscal year
    2010.
        However, because our projections regarding increased capacity
    resulting from increased FTE are not as large as the projected
    increases in workload, the agency still projects a net increase in the
    ``matters pending'' at the end of the current fiscal year, and fiscal
    year 2010.
        The impact of this continuing increase in the projected work load
    for SOL will require the agency to work intensively with the Secretary
    and client agencies to ensure that SOL's resources are focused on the
    matters that are most significant in advancing the goals of the
    Department and its agencies. Put simply, SOL will continue to be
    required to ``triage'' matters so as to take action regarding those
    that are more critical to the successful achievement of the Secretary's
    goals and DOL agency strategies.

                                                UPDATED WORKLOAD SUMMARY
    ----------------------------------------------------------------------------------------------------------------
                                                                        Fiscal year     Fiscal year     Fiscal year
                                                                        2008 actual     2009 target     2010 target
    ----------------------------------------------------------------------------------------------------------------
    Legal services:
        Litigation:
            Matters received........................................          17,059          17,997          18,987
            Matters concluded.......................................          14,507          14,870          16,506
            Matters pending.........................................          15,438          18,565          21,046
        Regulation:
            Matters received........................................             126             139             139
            Matters concluded.......................................             121             133             140
            Matters pending.........................................             143             149             148
        Opinion/advice:
            Matters received........................................           7,980           8,419           8,882
            Matters concluded.......................................           7,579           8,110           8,860
            Matters pending.........................................           5,691           6,000           6,022
    Budget activity total...........................................          94,900         108,364         125,226
    ----------------------------------------------------------------------------------------------------------------

                   flex-options project at the women's bureau
        Question. In the congressional budget justification, the Department
    states that it intends to continue and improve the Flex-Options project
    at the Women's Bureau. How much is currently spent on this project and
    how much is included in the 2010 budget request? What has been the
    experience with this project and associated outcomes? What changes are
    being considered for the project?
        Answer. Launched in 2004, the Women's Bureau Flex-Options project
    encourages business owners of all sizes and types to establish or
    expand workplace flexibility policies and programs such as
    telecommuting, part-time work, job-sharing, and compressed workweeks.
        For fiscal year 2009, the Women's Bureau will spend approximately
    $2 million on the Flex-Options project and plans to spend a similar
    amount in fiscal year 2010. Flex-Options has the equivalent of over 12
    FTEs, spanning national and regional office activities, dedicated to
    the project, as well as national and regional contractors who also
    support Flex-Options. The contracts, which total $200,000-$300,000
    annually, help manage the website, create and distribute newsletters
    and a Flex-Options toolkit, as well as work with companies to set up
    flexible workplace options.
        While the Department has not conducted an impact evaluation to
    determine the outcomes of the project (e.g., whether it increases the
    number of programs or employees that have access to new flexible
    policies/programs), the number of employers participating in the Flex-
    Options project has increased each year. Over the life of the project,
    Flex-Options has assisted over 800 employers in creating or expanding
    more than 1,800 workplace flexibility policies, affecting 1 million
    employees.
        In addition to reaching out to more employers, the Bureau is also
    expanding outreach and educational efforts to State/local governments
    and university consortiums of employers to promote workplace
    flexibility as a way to achieve environmental goals (e.g., improved air
    quality) or meet economic challenges. In 2008, Flex-Options had
    successful partnerships with the cities of Houston and Atlanta to
    encourage city governments in supporting flexible workplace options.
    The Women's Bureau is continuing to work with local governments in
    2009, as well as expanding to university consortiums in 2010.
        Workplace flexibility is a powerful response to the needs of
    millions of women and men who face the challenge of trying to balance
    the demands of their jobs and the needs of their families. It is also a
    vital tool that progressive companies are using to get work done, and
    it is a tool that can be used as a strategic component of any workplace
    contingency plan.
                                  ilab funding
        Question. The Bureau of International Labor Affairs (ILAB) is
    requesting an increase of more than $5 million and 12 FTEs in the
    fiscal year 2010 budget request. To which ILAB office or offices and
    for what activities would ILAB allocate these additional staffing
    resources requested under the budget request? ILAB has approximately
    140 projects in more 80 countries around the world. Does the requested
    increase provide additional funds/FTEs to oversee this significant
    investment of taxpayer resources?
        Answer. ILAB's budget has been constrained in recent years, while
    its mandates have expanded significantly. This budget increase allows
    ILAB to more fully and effectively meet its responsibilities. One of
    the primary purposes of the increased funding and FTEs is to increase
    ILAB's capacity to address the implementation of the labor commitments
    in U.S. FTAs--an area that has not been adequately supported in the
    past. ILAB will also strengthen its oversight, monitoring, and
    evaluation functions and reinforce its research activities to ensure
    that ILAB reporting is more analytical and strategically useful to
    Congress and the public.
        Roughly $1.56 million of the additional $5 million requested in
    fiscal year 2010 will be used to fund 12 new FTEs. The Bureau will hire
    comparative labor law experts, development and labor economists and
    international relations officers. The Bureau also plans to hire a
    career Associate Deputy Undersecretary to assist with the overall
    management and operation of the Bureau. ILAB will use about $2 million
    for monitoring, enforcement, and cooperative activities and $1.44
    million for research and reporting.
        The fiscal year 2010 funding increase ensures effective oversight
    of our extensive technical assistance programs to combat child labor
    and improve working conditions overseas, improved reporting on child
    labor, forced labor, human trafficking, and other core labor standards,
    and improvements in the labor diplomacy portfolio of the Bureau.
                            ilab's project portfolio
        Question. In the 2009 appropriations act, Congress stated its
    intention for ILAB to have sufficient funding to effectively oversee,
    monitor, audit, and evaluate ILAB's project portfolio. How would the
    fiscal year 2010 budget request allocate funding to ensure that this
    priority is addressed, particularly in the child labor project
    portfolio which is the most significant part of ILAB's project
    portfolio?
        Answer. The 2010 budget request includes additional funding and
    FTEs to ensure that ILAB has the resources needed to properly oversee,
    monitor, audit, and evaluate its ongoing technical cooperation
    programs, including those to combat exploitive child labor. ILAB's
    experience has demonstrated the importance of funding for such
    oversight in order for ILAB to assess project performance, take
    corrective actions where necessary, and as a result, to maximize the
    impact of the funding ILAB allocates for these projects. Funds
    requested in the fiscal year 2010 budget reflect ILAB's understanding
    of the actual costs associated with such oversight activities, and ILAB
    believes the requested level of resources will allow ILAB to fulfill
    its responsibilities related to program oversight.
                                  ilab funding
        Question. The congressional budget justification notes that ILAB
    plans to significantly improve its ability to monitor labor issues in
    Free Trade Agreement (FTA) countries, provide a strengthened mechanism
    for enforcement of trade agreements, develop cooperative activities
    with FTA partners, and research facts relating to specific labor
    situations and submissions. Please indicate what specific actions ILAB
    intends to take and how it will work with other Federal agencies to
    carry-out these activities? Does the President's budget include funding
    for other Federal agencies that will be transferred to ILAB in support
    of this effort? If so, how much funding is included in the budget
    request and for what activities?
        Answer. The requested increase of $5,000,000 would enable ILAB to
    develop systematic monitoring and analysis of labor issues in FTA
    countries. It includes additional staff that has the expertise to
    collect, analyze, and engage with partner countries to address
    deficiencies in labor law and practice. It also includes resources to
    provide cooperative assistance to trade partners to address labor
    deficiencies, such as providing expert assistance from DOL or other
    recognized sources. Importantly, when engagement and cooperation are
    not sufficient, the additional resources would enable ILAB to pursue
    enforcement of the labor obligations of the FTAs, including use of
    dispute settlement provisions. The labor obligations of our FTAs should
    be enforced just as our commercial obligations have been.
        In order to carry out these activities, ILAB will have the primary
    responsibility for conducting the proposed monitoring and analysis of
    labor issues. However, ILAB will work closely with labor officers in
    U.S. missions, and relevant staff at USTR, State, and other agencies.
    For example, the Department of Labor will take the lead in developing
    annual labor-related strategic plans of engagement for each FTA
    partner, which will be coordinated with USTR, State, and other relevant
    agencies to address labor issues in trade partner countries. On
    enforcement issues involving FTA obligations, ILAB will work closely
    with USTR on developing and pursuing dispute settlement cases. While
    these activities would represent a shift in focus to more active U.S.
    Government engagement on labor issues, the burden of the activity would
    rest with ILAB. ILAB would not be assuming functions that are already
    being carried out by other Federal agencies.
                        departmental program evaluations
        Question. The 2010 budget request includes $5 million to, among
    other things, fund high-quality evaluations of its programs, including
    those outside of job training and employment. Specifically, what
    activities are under consideration for evaluation, if the requested
    funds are provided? How would the $5 million request be allocated among
    this initiative's activities, including new evaluations, high standards
    in evaluations funded by the Department, building evaluation capacity
    in the Department and making sure evaluations/research findings inform
    policymakers and program managers?
        Answer. The $5 million for Departmental Program Evaluations is to
    conduct high-quality evaluations of DOL programs beyond job-training
    and employment services, which are currently evaluated using resources
    appropriated to the Employment and Training Administration. At this
    point, an evaluation agenda has not been finalized, but priority will
    be given to large, lightly examined, and/or high-priority programs.
    This effort could be focused on any of the worker protection agencies.
    There will also be an effort to ensure the rigor of evaluations
    Department-wide.
                          performance targets for odep
        Question. Under the budget proposal, the performance targets for
    the Office of Disability Employment Policy (ODEP) go down from the
    results achieved in fiscal year 2008. In the case of the number of
    policy-related documents, there is a reduction from 44 in fiscal year
    2008 to 32 in fiscal year 2010; for formal agreements, the reduction is
    26 in fiscal year 2008 to 22 in fiscal year 2010 and for effective
    practices the reduction is 37 in fiscal year 2008 to 23 in fiscal year
    2010. What has been the impact of ODEP's policy documents, formal
    agreements, and effective practices? Do these document and agreements
    impact disability employment policies across the Federal Government?
    Will the Department explain why a reduction in performance is estimated
    for ODEP?
        Answer. ODEP's annual performance output measures are designed to
    capture the annual results of the agency as it works to develop policy
    for implementation across the Federal Government that will reduce
    barriers to employment for people with disabilities. ODEP has been
    tracking effective practices since fiscal year 2004 and policy
    documents and formal agreements since fiscal year 2006. ODEP created
    output measures that recognize that policy development often occurs
    across fiscal years. ODEP's annual targets are based on an average of 3
    prior years of results, plus 10 percent. The targets are set with this
    formula to account for fluctuations in resources or other anomalies
    that could impact ODEP's performance. As it does every year, at the end
    of fiscal year 2009, ODEP will assess its performance and revise its
    annual performance output targets as necessary. Under its new
    leadership, ODEP also plans to revisit its performance measures.
        Since its creation in fiscal year 2001, ODEP has developed policy
    documents, established a wide range of formal agreements, and
    identified, validated, and assisted with the replication of effective
    practices. These activities have helped to reduce barriers to
    employment that exist in workforce systems, workplaces, and in
    employment-related supports programs and services (e.g.,
    transportation, healthcare, technology). ODEP's results have influenced
    policy and practice within the Department of Labor and across the
    Federal Government, State and local governments, nongovernmental
    organizations, and large and small businesses. A few examples of ODEP's
    work with regard to disability employment policies across the Federal
    Government over ODEP's history are included below.
        ODEP's work with adult-focused workforce systems is exemplified by
    the development and implementation of the WIA section 188 Memorandum
    and Checklist. This formal agreement signed by the Department's Office
    of the Assistant Secretary for Administration and Management, ODEP, and
    ETA provided One-Stop Career Centers with measurable ways to comply
    with section 188 of the WIA and documented strategies for One-Stop
    Career Center staff and other workforce system personnel to more
    effectively respond to the needs of people with disabilities.
        ODEP's work with youth-focused workforce systems is demonstrated by
    the Transition Programs and Services: High School/High Tech and
    Vocational Rehabilitation Information Memorandum (RSA-IM-07-08). This
    policy document was developed under ODEP's leadership in collaboration
    with the Departments of Health and Human Services and Education (OSERS/
    RSA). It provides information to State Vocational Rehabilitation
    agencies about ODEP's High School/High Tech program as a comprehensive
    transition program model with a number of promising practices that is
    based upon the Guideposts to Success, also developed by ODEP.
        ODEP has worked to influence employer policy through the Office of
    Federal Contractor Compliance Programs (OFCCP) Directive, Transmittal
    Number: 281, OFCCP ORDER NO.: ADM Notice/Other--Federal Contractor's
    Online Application Selection System. This policy document, developed by
    ODEP's leadership in collaboration with OFCCP, provides guidance on
    enforcing section 503 of the Rehabilitation Act of 1973 and the Vietnam
    Era Veterans' Readjustment Assistance Act of 1974 (VEVRAA). It requires
    that all compliance evaluations include a review of the contractor's
    online application systems to ensure that the contractor is providing
    equal opportunity to qualified individuals with disabilities and
    disabled veterans.
        Finally, a result of ODEP's effort and collaboration with the
    Bureau of Labor Statistics is the recent and historical publication of
    the unemployment rate for people with disabilities as part of the
    Current Population Survey. ODEP's leadership in collaboration with the
    BLS and the Census resulted in this significant accomplishment. This
    data will be used by agencies in the Department, other Federal
    agencies, and other stakeholders critical to addressing disability and
    employment issues.
                        disability navigators initiative
        Question. The fiscal year 2010 congressional budget justification
    indicates that a comprehensive evaluation of the Disability Navigators
    initiative is in the works and scheduled to be completed sometime
    around the end of 2010. Yet the budget proposes to establish a new $10
    million Competitive One-Stop Grant program based on the lessons learned
    from the Disability Navigator program. Specifically, what lessons
    learned would the Department of Labor apply in this new program? Using
    what evaluation were these lessons learned?
        Answer. Although the comprehensive evaluation of the Disability
    Navigators initiative will not be completed until late fiscal year
    2010, the Department has identified numerous sources of interim data
    and other feedback to support moving to the next step for this critical
    effort. These sources include the ETA Forum on Disability Program
    Navigator (DPN) Initiative--Role and Impact (June 2009), and
    evaluations of ODEP's Customized Employment demonstration projects
    housed in One-Stop Career Centers that coordinated with Disability
    Program Navigators to ensure meaningful and effective service to
    customers with disabilities (Evaluation of Disability Employment Policy
    Demonstration Programs: A Synthesis of Key Findings, Issues, and
    Lessons Learned--Customized Employment Program Priority Area, WESTAT,
    October 2007; Employers and Workers: Creating a Competitive Edge,
    Summary Report on Customized Employment Grants and Workforce Action
    Grants, National Center on Workforce and Disability/Adult, July 2007).
        The DPN initiative has two purposes for ensuring that job seekers
    with disabilities receive meaningful service at One-Stop Career
    Centers. These include (1) the responsibility to ensure the appropriate
    provision of service to individuals, and (2) the responsibility to
    reach out to and coordinate with other systems and agencies identified
    under the WIA, as well as reach out to and coordinate with additional
    systems that provide specific service to people with disabilities. The
    overall goal is more effective coordination and integration of
    resources and customer support across multiple systems--an essential
    charge of the WIA and a critical need for people with disabilities.
        In particular, based on available information the DPN initiative
    identified effective practices for serving people with disabilities
    that touch on all aspects of One-Stop operations: marketing and
    outreach; orientation; assessment; service coordination; service
    delivery; and business services. Central to these practices was the
    concept of the One-Stop as the hub of activity and support for
    workforce entry, securing needed supports and leveraging funding across
    multiple systems, and ensuring effective job placement. In their work,
    the navigators found that people with disabilities benefited from their
    expertise in navigating multiple social service systems. If a job
    seeker required assistance with transportation or housing, or
    assistance accessing needed Social Security or Medicaid benefits, the
    navigator often became the ``go-to'' person. Based on this preliminary
    evidence, there is a continued need to equip One-Stop Career Center
    staff to help individuals with disabilities navigate across service
    systems.
        The case examples and informal feedback from the field have
    underscored the value of integrating the navigator function into One-
    Stop operations and the need for ETA to take the lessons learned to a
    national scale. ODEP is analyzing data and feedback on the DPN
    initiative and the agency's own external evaluations of projects housed
    in One-Stop Career Centers, to determine specific next steps in
    building a system responsive to the needs of job seekers with
    disabilities. A partnership between ETA and ODEP in this regard offers
    unique opportunities for the provision of national technical assistance
    and rapid dissemination of information to the field, as well as
    additional feedback based on the continued experiences of One-Stops as
    they develop effective and fully accessible services and facilities for
    all job seekers.
       improving the employment process for individuals with disabilities
        Question. The 2010 congressional budget justification also
    indicates that ``ODEP will partner with the Department of Education's
    Rehabilitative Services Administration and others to develop policy and
    effective practices to improve One-Stop employment outcomes for
    individuals with Disabilities.'' What specific actions would the 2010
    budget request support? To date, what specific policies or practices
    has ODEP developed in support of this effort?
        Answer. In 2010, ODEP will partner with the U.S. Department of
    Education's Rehabilitative Services Administration (RSA) and others to
    undertake a new $10,000,000 competitive grant program that will focus
    on One-Stops, and work with employers, labor-management partnerships,
    labor unions, and other stakeholders to improve the employment process
    for individuals with disabilities utilizing pre-apprenticeship and
    apprenticeship programs, and career-related community service
    opportunities. In developing this program, ODEP will build upon the
    lessons learned from the Disability Navigator Program, and other ODEP
    projects as they relate to effectively coordinating training and the
    delivery of other needed services to people with disabilities within
    the One-Stop system. In addition, ODEP will work with ETA to identify
    policies and practices that have proven effective in the development of
    meaningful partnerships with community-level partners that provide
    employment-related services to youth and adults with disabilities.
        With regard to what specific policies or practices ODEP has
    developed in support of this effort, the following are noteworthy. ODEP
    collaborated with ETA in drafting and issuing a Self-Employment
    Training for Workforce Investment Act Clients--Technical Employment
    Guidance Letter (TEGL) 16-04 2005 describing the authorities provided
    by the WIA for One-Stops to provide entrepreneurship training and to
    identify resources that can support the efforts of people with
    disabilities to start businesses.
        ODEP collaborated with DOL's ETA and its Civil Rights Center to
    jointly develop and issue the WIA section 188 Memorandum and Checklist.
    The checklist provides a uniform procedure for measuring compliance
    with those provisions of section 188 of the Workforce Investment Act of
    1998 and the implementing regulations (29 CFR Part 37) that pertain to
    persons with disabilities for physical, programmatic, and communication
    accessibility. Any technical assistance provided by ODEP to the One-
    Stops will use this checklist as a resource.
        ODEP has worked with ETA's Office of Apprenticeship in 2009 to
    research, test, and evaluate innovative systems models for providing
    inclusive integrated apprentice training in a high-growth industry to
    youth and young adults with disabilities, aged 16 to 27, including
    those with the most significant disabilities, that utilize the
    increased flexibilities detailed in DOL's newly released apprenticeship
    regulations regarding the provision of training and interim
    credentialing. ODEP implemented a 6-year demonstration to advance
    customized employment in One-Stop Career Centers. Lessons learned from
    this initiative will be used to design the next step in creating a
    universally accessible workforce development system.
        In the summer of 2009, ODEP and ETA's Office of Apprenticeship will
    issue a joint Training and Employment Notice. This notice will
    disseminate a white paper and toolkit developed through ODEP's research
    and technical assistance activities which focus on expanding
    apprenticeship opportunities for youth and young adults with
    disabilities. The white paper entitled Improving Transition Outcomes of
    Youth with Disabilities by Increasing Access to Apprenticeship
    Opportunities, which is geared to policymakers, provides an overview of
    the Registered Apprenticeship system in the United States, explores
    current trends in apprenticeship, and examines opportunities for youth,
    including those with disabilities. In addition, it identifies obstacles
    to expanding participation of youth with disabilities in apprenticeship
    programs and provides strategies for addressing these obstacles. The
    toolkit, entitled Youth with Disabilities Entering the Workforce
    Through Apprenticeship, is intended to provide service providers with
    useful information about apprenticeship as an employment strategy for
    youth and young adults with disabilities.
        As the result of a 3-year ODEP-initiated effort with DOL's Office
    of Apprenticeship, and the Employment Standards Administration's WHD,
    the Office of Apprenticeship added language to their new regulations to
    allow apprenticeship programs to be customized to provide intermediate
    levels of certification for apprentices to demonstrate their level of
    proficiency in apprenticeable occupations.
        In planned future activities, ODEP will build on its prior policy
    efforts to support entrepreneurs with disabilities through technical
    assistance and grants. ODEP will fund a workforce-systems focused
    cooperative agreement to support mentoring opportunities for young
    people with disabilities from minority communities who are
    transitioning from school (secondary or postsecondary) and interested
    in entrepreneurship. In developing this initiative, ODEP will partner
    with stakeholders in the public and private sectors, including minority
    Chambers of Commerce, and leverage existing resources on mentoring and
    entrepreneurship developed by ODEP. ODEP will also work with ETA to
    evaluate the physical and programmatic accessibility of the One-Stop
    Center system, and partner with ETA and Labor's Civil Rights Center as
    appropriate to address any identified deficiencies through the
    expansion and adoption of universal strategies, the provision of
    targeted technical assistance, and other corrective measures deemed
    necessary.
                              job corps operations
        Question. The budget indicates that $8 million of the $16.923
    million increase for Job Corps will be for the opening of the Milwaukee
    Job Corps center, with the remaining $8.923 million for the remaining
    123 Job Corps centers. is this amount sufficient to offset the rising
    costs of operating Job Corps centers?
        Answer. The fiscal year 2010 request for Job Corps Operations is
    $1,557,199,000, an increase of $16,923,000 over the 2009 enacted level.
    This request will allow Job Corps to serve more youth than in 2009,
    support anticipated increases in fixed costs at centers, and fund cost-
    of-living increases for Federal staff at 28 Agency-operated centers.
    Only Federal employees at the Agency-operated centers are eligible to
    receive the federally mandated cost-of-living increases.
        The fiscal year 2010 request supports 44,950 student slots-an
    increase of 495 over the 2009 targeted level. The request includes
    funding for additional slots at the new Milwaukee Job Corps Center,
    scheduled to open in program year 2010. The fiscal year 2010 request
    also provides increases for some critical activities including funding
    for workload increases for Outreach/Admissions and Career Transition
    contracts. It also supports the anticipated increases in fixed costs at
    centers, such as utilities and GSA vehicle rental, and includes
    sufficient funds for mandated cost-of-living increases for the Federal
    staff at the 28 Agency-operated centers. Job Corps remains committed to
    improving program efficiency without compromising the basic services,
    such as academic and career technical training, provided to our
    enrollees.
        Additionally, Job Corps will use $36 million in Recovery Act funds
    to support critical IT infrastructure and operations needs. The
    Recovery Act funds designated for green jobs training will allow us to
    realize operational savings in the areas of Career Technical Skills
    Training supplies and materials for hands-on training projects. It will
    allow the program to increase the provision of green jobs training so
    that at-risk youth who participate in Job Corps will be well situated
    to benefit from the new green economy.
        Question. How will centers achieve the vision of building a
    standards-based education and training system under the budget request?
        Answer. It will be a challenge, but the Department remains
    committed to improving program efficiency without compromising basic
    services, such as academic and career technical training, provided to
    our enrollees. While Job Corps' legislative mission remains the same--
    to educate and train promising youth to be productive workers and
    citizens--how Job Corps performs this mission is being significantly
    transformed. At the heart of Job Corps' new direction is the
    implementation of a Standards-based Education and Training System
    leading to industry-recognized credentials and certifications for
    students, staff, and programs, and the system-wide structural and
    organizational changes concerning professional development, policy,
    technology and related areas essential to achieving the transformation.
    Job Corps' transformation is occurring incrementally and over time in
    four phases. Job Corps has recently completed phase two, the
    development of 38 national Career Technical Training programs which
    have been revised and aligned with industry standards and
    certifications. In phase three, Job Corps will extend the
    implementation of these programs to all centers system-wide. By program
    year 2010, the Department of Labor expects Job Corps to begin phase
    four, the full-scale, nationwide implementation of a fully-tested,
    evidence-based National Model of standards-based education and
    training.
        Question. Are there specific cost-savings or efficiencies that the
    Department believes can be implemented? If so, please explain what they
    are and how much can be save through these initiatives.
        Answer. Job Corps intends to achieve cost savings and efficiencies
    through the use of energy efficient construction methods, fleet
    reduction and the increased use of alternative fuel vehicles. As a
    result, we estimate a savings of up to $5 million annually.
        The recently awarded Iowa Job Corps Center construction project
    will utilize energy efficiencies such as a ground source heat pump,
    upgraded wall and roof insulation, lighting controls, high-efficiency
    lighting, Energy Star equipment, and low flow plumbing fixtures. By
    building to these specifications Job Corps estimates that annual energy
    costs at this center will be reduced by $82,000 annually compared to
    construction that does not incorporate these efficiencies.
        Job Corps will gain vehicle efficiencies by simultaneously reducing
    the overall size of its fleet while increasing the number of
    alternative fuel vehicles (AFVs). Recovery Act funds are being used to
    purchase electric vehicles for use at each Job Corps center. These
    American-made electric vehicles will supplant petroleum-based vehicles
    currently in use on centers in such areas as maintenance, security,
    administration, and program operations. The net result for centers and
    for Job Corps is greater fleet efficiency and lower carbon emissions
    for the same vehicle miles driven.
                    slot reallocations at job corps centers
        Question. The congressional justification also indicates that in
    fiscal year 2009 that ``slots will be re-allocated from centers with
    continuing low on-board strength to high-performing centers that have
    been successful in the recruitment and retention of students.'' What
    standards will be adopted for such reallocations for both low on-board
    strength and high-performing centers?
        Answer. Job Corps longstanding position is that it is not prudent
    to allow some centers to maintain empty training slots year after year
    when there are centers with waiting lists. To ensure that there are
    opportunities for all students wanting to enroll in the program,
    reallocating slots from centers that underutilize slots promotes an
    effective use of funds. Job Corps will conduct a detailed analysis of
    the low on-board strength (OBS) centers to determine the appropriate
    number of slots that should be moved from one center operator's
    contract and added to another. The analysis examines on-board-strength
    data and the performance data for all centers to determine those
    centers with continuing low OBS and their performance levels.
    Implementation of slot reallocation will coincide with the start of a
    new contract year for the center to ensure that there are minimal
    disruptions in service. The most recent analysis of low on-board
    strength was done in early 2007 and at that time, there were nearly
    4,000 empty training slots across the program. Centers with low OBS had
    slots reallocated to other centers, including New Orleans, Little Rock,
    and Cleveland.
        Question. How much would be reallocated in 2009 under this
    reallocation strategy?
        Answer. No determination has been made for program year 2009 yet.
    The Office of Job Corps will present options to the Office of the
    Secretary for program year 2009.
        Question. Would this same strategy be needed in fiscal year 2010 at
    the requested funding level?
        Answer. There may be a need to utilize the same strategy in 2010 if
    it is determined that there are still centers that are unable to fill
    their allocated training slots and there are still waiting lists.
                                     ______

                Questions Submitted by Senator Daniel K. Inouye
              responding to worker displacement in american samoa
        Question. As a result of Public Law 110-28, the minimum wage was
    increased in American Samoa and the Commonwealth of the Northern
    Mariana Islands (CNMI) by $0.50 per hour on July 24 and July 25, 2007,
    respectively. While opposed by the Congressional Delegates and
    Governors representing both territories, Public Law 110-28 also
    mandated automatic increases of $0.50 per hour every year thereafter
    until 2014 for American Samoa, and 2015 for the CNMI.
        After conducting an 8-month study of both economies, as mandated by
    Public Law 110-28, the U.S. Department of Labor (DOL) concluded that
    automatic increases would be harmful to both economies, although each
    economy was able to sustain the first increase. Given Chicken of the
    Sea's recent announcement to close its operations in American Samoa
    which will lead to the displacement of more than 2,100 workers, will
    the DOL support congressional action to place a hold on future
    increases until such time as the Government Accountability Office (GAO)
    can conduct a new study, due in April 2010, regarding the impact of
    past, present, and future increases on both economies?
        Answer. The Department must correct a misunderstanding of its
    report on the impact of the minimum wage increases on the economies of
    American Samoa and the CNMI. The DOL report produced during the prior
    administration was undertaken shortly after the first increases in the
    minimum wage, which limited the Department's ability to measure the
    impact. The report did not explicitly recommend a roll back. My staff
    has reviewed the report and based on the lack of detailed data they
    have concluded that it is very difficult to separate possible effects
    of the minimum wage increases from the effects of other economic
    forces. As noted in the report, the ability of the Department to fully
    assess and project the impacts of increases in the minimum wages
    applicable to American Samoa and the CNMI was constrained by the short
    timeframe available for observation of emerging effects and by the lack
    of timely labor market data for both territories. The fact that the
    increases are scheduled to be implemented gradually over an extended
    period of years is reason to expect that adverse impacts, if any, will
    be minimized, and the increase in earnings and spending power of island
    households as a result of the minimum wage increase will benefit the
    local economies.
        The closing of Chicken of the Sea's operations in American Samoa
    cannot be directly attributed to the expected minimum wage increase
    because the company moved its operations to the State of Georgia, where
    the higher Federal minimum wage applies. (The Federal minimum wage is
    currently scheduled to increase to $7.25 on July 24 of this year, while
    the American Samoan minimum wage for the fish canning and processing
    industry will remain at $4.76).
        Currently, the GAO is conducting a study of the impact of the
    minimum wage increase on American Samoa and the CNMI. The Department
    will certainly consider any legislation proposed by the Congress.
        Question. According to Congressman Faleomavaega, until passage of
    Public Law 110-28 and due to the territory's unique and fragile
    economy, DOL Special Industry Committees historically determined
    minimum wage rates in American Samoa. Would the administration support
    the Congressman's position of reinstating a modified version of Special
    Industry Committees for American Samoa and the CNMI in lieu of
    automatic increases as now mandated by Public Law 110-28?
        Answer. The Department will consider any legislation proposed by
    the Congress.
        Question. I am advised by Congressman Faleomavaega that more than
    2,100 workers in American Samoa will be displaced in September of this
    year when Chicken of the Sea relocates to Lyons, Georgia. Would the DOL
    support efforts to redirect a portion of the stimulus funds, held by
    DOL for American Samoa, to unemployed workers for purposes of job
    training and unemployment compensation, in view of the fact that the
    American Samoa government does not participate in the Unemployment
    Insurance program?
        Answer. The Department is aware of the worker displacement
    occurring in American Samoa, but does not have the authority to allow
    Recovery Act funds to be used as a substitute for unemployment
    insurance benefits. However, the Department recommends that the
    American Samoa government consider submitting a National Emergency
    Grant proposal that could provide job training, needs related payments,
    and other employment services to assist workers affected by the Chicken
    of the Sea relocation. Our office of Congressional and
    Intergovernmental Affairs and the Employment and Training
    Administration have had several discussions with Government officials
    about the process for applying for such a grant.
                                     ______

                  Questions Submitted by Senator Patty Murray
             further collaboration with the department of education
        Question. I am concerned about those in our workforce that are not
    prepared for a turbulent, knowledge-based, technology-driven economy
    because they do not have the basic skills required by business to
    succeed in tomorrow's workplace. While 25 percent of today's jobs
    require a postsecondary credential or degree, an estimated 45 percent
    of all new jobs over the next decade will require such postsecondary
    credentials. More than 12 million adults without high school
    credentials are in the labor force today, and over 1 million young
    adults drop out of high school each year. We are the only highly
    developed democracy where young adults are less likely to have
    completed high school than the previous generation. I believe that
    adult education and literacy is a very important component of the
    workforce system.
        Have you and Secretary Duncan discussed how both departments can
    better meet the needs of the ever growing list of those seeking and
    needing adult education services--including basic education, English
    language training, and high school diploma preparation, to succeed in
    careers?
        Answer. The Departments of Labor and Education have a long history
    of collaboration and have developed venues that will allow both
    Departments to continue to work together to find better and more
    effective ways to meet the needs of adults seeking education services.
    We have begun working with the Department of Education to develop
    proposed principles for re-authorizing WIA in order to ensure that
    education and training activities are delivered in a manner that
    provides the best results of these joint investments. In addition, both
    Departments are active members of the Adult Learning Strategies
    Workgroup. This workgroup serves to identify and integrate Federal
    programs and services to develop new service models and promote adult
    education and literacy.
        Recently, Labor issued Training and Employment Guidance Letter 14-
    08 directing that Workforce Investment Act (WIA) funds included in the
    Recovery Act may be used for adult education, including basic or
    English language education, as delivered through community colleges and
    other high-quality public programs and community organizations that
    provide such services. Secretary Duncan and I are working to ensure
    that other substantial investments made possible by the Recovery Act,
    such as the $500 million made available for grants in the renewable
    energy and energy efficiency industries, will include provisions
    promoting services with a focus on degree or certificate attainment for
    low-income and displaced workers, and for high school dropouts. To
    support these efforts the Departments of Education, Energy, and Labor
    have entered into a Memorandum of Understanding (MOU) intended to
    strengthen communication and the partnerships among the three
    Departments. Some of the activities that will result from the MOU
    include: (1) each Department notifying the other two Departments of
    relevant awards made with Recovery Act or appropriated funds; (2) each
    Department disseminating information about relevant programs and
    activities carried out by the other two Departments; and (3) the
    Departments working together to develop mutually supportive and
    reinforcing projects with aligned goals to ensure the development of
    career ladders, lattices, and pathways for jobs in energy efficiency
    and renewable energy fields.
        Another example of our collaboration concerns the next round of
    Community-Based Job Training grants, funded by our fiscal year 2009
    appropriations. The grants have historically focused on expanding the
    capacity of community colleges to deliver training for high-growth
    industries. As we shape the next competition, we will work to ensure
    that connections to basic education services are available through
    these grants so that individuals who need to obtain a high school
    diploma or equivalent before progressing to postsecondary level
    education can do so. This approach will align with the fiscal year 2010
    budget's proposal for a ``Career Pathways Innovation Fund'' where we
    would emphasize basic education, English as a Second Language and other
    remediation that prepares individuals to take clear sequences of
    coursework to obtain credentials that lead to better jobs. As part of
    this initiative, we will work with the Department of Education to help
    develop program requirements.
        Finally, I believe that two of the key components of WIA
    reauthorization will be creating a system where adults can move easily
    between the labor market and further education and training in order to
    advance in their careers and the close alignment of every level of
    education and training with economic realities. In the months ahead, I
    look forward to working with Secretary Duncan and Congress to take
    advantage of the opportunities created by WIA reauthorization to
    identify strategies that will better promote and provide adult
    education services to those who need them.
                              wia youth activities
        Question. I commend you for your Department's timely Recovery Act
    guidance to the workforce community regarding the use of Workforce
    Investment Act (WIA) formula funds. Your guidance accurately reflects
    our statutory mandate. We want to ensure these workforce funds are
    spent well and utilized during this time of economic crisis.
        Unfortunately, the state of our economy has worsened dramatically
    since that time, and employment prospects for youth look particularly
    bleak this summer, which is why Congress dedicated $1.2 billion in the
    Recovery Act for the Department of Labor to help at risk youth--with a
    particular focus on providing jobs this summer. I know that your staff
    has been working with State and local areas, encouraging them to run
    robust summer jobs programs this year.
        What can you tell us about your expectations this summer?
        Answer. During the summer of 2009, the Employment and Training
    Administration (ETA) expects to serve between 200,000 to 250,000 youth
    in summer employment, funded by Recovery Act WIA youth funds. Based on
    State and local readiness reviews, local areas are ready to implement
    robust summer employment opportunities this summer, despite the short
    implementation time. ETA expects most local areas to spend roughly 70
    percent of their WIA Youth Recovery Act funds on summer employment
    during the summer of 2009. Some local areas report plans to spend their
    entire allocation of WIA Youth Recovery Act funds on summer employment
    this summer. ETA also expects many local areas to implement some form
    of ``green'' work experiences this summer, although developing
    ``green'' opportunities will take time and may not be widespread during
    the summer of 2009.
        Question. Should States and local areas rebuild and offer robust
    summer jobs programs in 2009 with funds from the Recovery Act, I'm
    concerned that they may not be able to sustain them at the recommended
    2010 level. As we move forward and learn about the impact of the
    Recovery Act funds, will you work with me and my colleagues to support
    a robust summer jobs program in 2010?
        Answer. States and local workforce areas are energized with the
    renewed focus on summer employment opportunities. Local areas should be
    able to use a combination of remaining Recovery Act funds, remaining
    regular WIA youth funds from program year 2009, and program year 2010
    WIA youth funds to continue operating summer employment opportunities
    during the summer of 2010.
                      high-growth job training initiatives
        Question. As you know, the Recovery Act included $250 million for
    competitive grants to better help meet the need for health care
    workers. I know that the Department is working hard to announce a grant
    solicitation in late spring or early summer for projects that train
    workers in the high demand sectors for the healthcare field such as
    nursing and allied health, where skilled worker shortages are expected
    to reach crisis proportions with the retirement of the baby boomers.
        How is the Department of Labor coordinating this effort with the
    $500 million that was allocated to the Department of Health and Human
    Services (HHS) for health jobs in the Recovery Act?
        Answer. Across the board, the Department is working with our
    Federal partners to connect our workforce development dollars with
    other agencies' research, infrastructure and workforce development
    dollars. We already have a collaborative working relationship with HHS,
    including the Health Resources and Services Administration, and are
    reaching out to others to coordinate our Recovery Act investments. For
    example, we anticipate linking to the newly created Office of the
    National Coordinator for Health Information Technology to better
    understand the job creation and skill needs that will occur as a result
    of those investments. Our goal is not only to link the $250 million for
    training in high growth industries, but to also link the Recovery Act
    WIA formula funding to opportunities that are represented by the
    resources available through HHS for healthcare jobs.
        Question. How can we maximize and better coordinate the health
    workforce initiatives being undertaken by both Departments in the
    fiscal year 2010 budget?
        Answer. The best way to maximize and coordinate both Recovery Act
    and funding through the normal appropriations process is through
    partnership activities. There are many opportunities to share
    information across systems, promote leveraging of resources at the
    local level, and collaborate on workforce solutions for the healthcare
    industry broadly. One approach that the Department of Labor has pursued
    in partnership with HHS and other Federal agencies is supporting
    States' efforts to convene and develop partnerships among providers
    from different programs and funding sources--either around a specific
    sector (such as nursing education capacity) or a specific population
    (such as disadvantaged youth). This effort has fostered a collaborative
    approach to problem-solving at the State and local level, which is
    where an integrated approach can have significant impact.
                transitioning veterans into civilian employment
        Question. Veterans and returning servicemembers have a difficult
    time transitioning to civilian employment for a number of reasons. And,
    I believe that it's our shared responsibility to ensure that those who
    have sacrificed for us on the battle field are fully supported as they
    re-enter civilian life and seek a new career or return to their former
    job. Part of helping ease that transition is creating seamless service
    provision for these members across the Federal Government.
        I was glad to see that this budget request includes additional
    funds for the Veterans' Employment and Training Services Administration
    and other veterans' employment programs at the Department of Labor. But
    I'm concerned that the agencies that serve our veterans need to do more
    to align their services and ease the burden on servicemembers seeking
    their rightfully earned benefits.
        How will you work with the Department of Veterans Affairs, the
    Department of Defense, and other agencies to help ensure veterans
    transition successfully into civilian employment?
        Answer. The Department of Labor along with the Departments of
    Defense (to include the Military Services), Veterans Affairs, and
    Homeland Security has an active Transition Assistance Steering
    Committee that oversees the Transition Services provided by these
    Departments to transitioning servicemembers. This Committee is
    responsible for recent improvements to Transition Services, which
    includes a standardized Transition Assistance Employment Workshop and
    the requirements for attendees to develop a resume. Based on the
    recommendations of the Committee the Department of Labor will conduct a
    TAP Review to assess the current curriculum and assess its relevancy
    and recommend changes and improvements.
        Question. How will you work with ODEP and other agencies within the
    Department to address the needs of veterans and servicemembers who
    suffer a disabling injury during their service and their families who
    care for them during this time who may fear putting their jobs at risk?
    I am particularly interested in your thoughts on how we can better help
    veterans with TBI successfully transition into the civilian world of
    work.
        Answer. VETS works closely with the Office of Disability and
    Employment Policy (ODEP). In consultation with VETS, ODEP established
    the Department's America's Heroes at Work program. This program
    addresses the employment challenges of returning servicemembers living
    with Post Traumatic Stress Disorder (PTSD) and/or Traumatic Brain
    Injury (TBI). The americasheroesatwork.gov web site for employers and
    the workforce development system, helps returning servicemembers
    affected by TBI and/or PTSD succeed in the workplace--particularly
    servicemembers returning from Iraq and Afghanistan. The VETS National
    Office is located adjacent to that of ODEP, which facilitates
    collaboration on projects serving the employment needs of disabled
    veterans. In recent years VETS and ODEP have been among the sponsors of
    the annual U.S. Business Leaders Network (USBLN) conference.
        A key employment initiative for which VETS has employed expertise
    and assistance from the ODEP is the Recovery and Employment Assistance
    Lifelines Program (REALifelines). REALifelines is a program sponsored
    by the U.S. Department of Labor, military medical transition centers,
    and career workforce agencies located in hometowns across the country.
    The program supports the economic recovery and reemployment of
    transitioning wounded and injured servicemembers and their families by
    identifying barriers to employment or re-employment and addressing
    those needs at the earliest point possible during transition from
    military service. ODEP has provided expertise to VETS regarding
    supporting and assistive services for this population of veterans. A
    venue for discussing associated issues is an ODEP America's Heroes at
    Work Committee on which VETS is a permanent member. The REALifelines
    program links servicemembers with local professionals in their hometown
    communities to support their economic recovery and re-employment
    through a range of services. As part of the program, wounded and
    injured servicemembers, and their spouses, are eligible for services
    offered at more than 3,000 One-Stop career centers of the Employment
    and Training Administration's Workforce Investment System.
                community service employment for older americans
        Question. The Senior Community Service Employment Program (SCSEP)
    is the only program at the Department of Labor that provides intensive
    services for low-income older workers. Its dual mission of both
    community service and employment is unique and highly effective,
    especially during these tough economic times. However, I am concerned
    that despite the worst unemployment levels for older workers since
    World War II, the Department's budget recommended a less than 1 percent
    increase for this program in 2010. Congress did provide $120 million in
    additional funds for SCSEP in the Recovery Act, but the program is
    still only able to serve less than 1 percent of the eligible
    population. And our low-income seniors are hurting.
        What plans do you have to strengthen and enhance the SCSEP program?
        Answer. The Recovery Act provided SCSEP with an additional $120
    million through the end of program year 2009. The regular program
    increase for program year 2010 will maintain the program at its current
    level. The program year 2009 funding and program year 2010 requested
    funding are each sufficient to fund 59,316 participant slots in the
    regular program per year, or approximately 91,000 individual persons
    each year, depending on the program turnover rate and the ability of
    participants to find unsubsidized employment.
        The Recovery Act funding will support approximately 13,000
    additional participants in program year 2009 and cover increased
    participant wages due to the July 24, 2009 increase in the Federal
    minimum wage. The total number of individuals served with Recovery Act
    funds is also dependent on the turnover rate and ability of
    participants to transition to unsubsidized employment.
        The Department intends to continue its effort begun last year to
    focus technical assistance on the lower performing grantees, helping
    them to appropriately evaluate and diagnose their performance issues to
    lead to more effective improvement strategies. The Department has begun
    utilizing more online training opportunities for grantees through
    Webinars and other electronic tools, thus enabling grantees to receive
    needed technical assistance at any time. Technical assistance is also
    focused on ensuring grantees effectively coordinate the delivery of
    services including encouraging better services for older workers at
    One-Stop Career Centers.
        In an effort to serve participants more effectively, the Department
    required in the 2006 competition for national grantees that national
    grantee service areas be more contiguous and less duplicative of other
    service providers. As a follow-up to this effort, the Department
    intends to work with the State and territorial grantees to consider
    more efficient assignment of their service areas which will encourage
    management efficiencies. This will need to be accomplished on a State-
    by-State basis before the next national grantee competition in 2011.
        Question. What plans do you have to better serve older workers
    through the One Stop Career Center network?
        Answer. The Department will soon launch an initiative to increase
    the public workforce system's capacity to effectively serve an aging
    worker population, as well as to train workers age 55 and older for
    jobs in high growth, high-demand industries that are critical to
    regional economies. The Department plans to award $10 million in grant
    funds to 10 organizations that connect older Americans to career
    opportunities through the ``Aging Worker Initiative: Strategies for
    Regional Talent Development.''
        The Department has developed a protocol on serving older workers
    aimed at the workforce system to articulate the various roles and
    responsibilities of all the stakeholders, including the One Stop Career
    Centers, the State and local Workforce Boards, mature worker
    intermediaries and service providers, business and industry employers,
    and the Department itself. This protocol was shared through Training
    and Employment Notice 16-04, Protocol for Serving Older Workers, and
    subsequently posted on our website for ongoing access. In the coming
    year, the Department plans to reinforce the activities articulated in
    the protocol.
        The Department has also encouraged enhanced services to older
    workers through the One Stop Career Center network through technical
    assistance that combined workshops and through online assistance on
    www.workforce3one.org, ETA's knowledge sharing and learning platform.
    Nearly 50,000 stakeholders from the workforce system use this Web site
    to participate in online learning events (Webinars); to learn about
    promising practices or new research on workforce topics; and to engage
    in networking opportunities with workforce system peers. In the past 3
    years, ETA has hosted numerous Webinars on effective strategies for
    serving older workers and current issues impacting older workers, such
    as displacement.
        Question. Will you be willing to work with Congress to do so?
        Answer. The Department will be happy year to work with Congress to
    ensure our programs are strengthened and enhanced to effectively serve
    older workers.
                        career pathways innovation fund
        Question. I am very interested in your Career Pathways Innovation
    Fund proposal in your 2010 budget request. As you know, developing
    career pathways is an important focus for me, and I look forward to
    working with you on this important initiative. I believe that we need
    to create strong career ladders that can help our students and current
    workers, regardless of their skill levels, move up the economic ladder.
        How do you envision the workforce system, community colleges, and
    our education systems coordinating with employers and labor
    organizations in high demand or emerging industry sectors to accomplish
    the goals of this program?
        Answer. We appreciate your interest in creating strong career
    ladders and helping workers advance in their careers. You are correct
    that partnerships will be key to implementing this new initiative. This
    initiative is the outgrowth of an industry sector approach to workforce
    solutions. Business, industry, and labor define competencies and skills
    and work collaboratively with education partners to map corresponding
    education and career pathways with supporting curriculum to achieve
    industry recognized credentials. The community college is the focus of
    this initiative, but there is an expectation that the development of
    successful career pathways program will require engagement with
    business and industry, the full spectrum of education partners, labor
    organizations, the workforce system, and others. There will also be a
    need to ensure that not only traditional students, but also dislocated
    workers and transitioning adults have access to the pathways. The
    workforce system is a key partner for this purpose. The Department
    intends to structure the competitive grant process to require these
    strategic partnerships.
                          work incentive grant program
        Question. We have heard much in a recent series of Workforce
    Investment Act listening sessions about the challenges many job seekers
    with disabilities have in accessing one stop services and through the
    centers and through their programs. Together with some of my
    colleagues, we sponsored these sessions where stakeholders in the
    system could provide feedback about what has worked and should be
    refined and retained to help workers, job seekers and industry; what
    key challenges need to be addressed; and what innovative policy ideas
    should be considered to modernize the WIA as we move forward with re-
    authorization.
        One of the key ways to improve accessibility for one stop services
    was the disability navigator system supported through the Work
    Incentive Grant program. While I understand the rationale for
    eliminating this program after a 7-year ``pilot,'' I'm concerned about
    the continuation of services provided by disability navigators or other
    promising practices to help individuals with disabilities through the
    One Stop system. And your budget states your expectation that there
    will be an increase in workforce service levels to job seekers with
    disabilities through the One Stop Career Center system in 2010.
        What are your plans to ensure that the State and local area One
    Stop service delivery networks meet this expectation, and how will you
    know whether it is met?
        Answer. While the Department has recommended phasing out direct
    funding for this program, it is actively working with States to utilize
    other available Federal and State resources to support the Disability
    Program Navigator model, such as Wagner-Peyser funding, and funding for
    participation as a Ticket to Work Employment Network. The
    administration and the Department continue to have a strong commitment
    to ensure that individuals with disabilities receive the services they
    need to be successful in the workplace.
        Furthermore, the Department recognizes that in an economic downturn
    and a tight labor market, individuals with more barriers to employment
    have the potential to be left behind. The Department is working to
    ensure all disadvantaged populations continue to have access to the
    resources of the public workforce system and benefit from the new
    infusion of resources provided by the Recovery Act. Specifically, the
    Department is requiring States specify how they will ensure a continued
    focus on disadvantaged populations (which include individuals with
    disabilities) in modifications to their WIA and Wagner-Peyser State
    Plans, which outline their Recovery Act strategies. In addition, we
    provide continuous technical assistance to the workforce system through
    Webinars and other means and have already produced a webinars focusing
    on how to ensure individuals with disabilities are served with these
    new resources.
        I have also requested an increase of $10 million over fiscal year
    2009 for the Office of Disability Employment Policy. This increase will
    support a new initiative that builds upon the lessons learned through
    the Disability Navigator Program, and focuses on working with
    employers, the One-Stop system, and other stakeholders to vigorously
    promote the hiring, job placement and retention of individuals with
    disabilities, particularly youth, in integrated employment,
    apprenticeship and pre-apprenticeship programs, and community service
    activities.
        Question. Will you keep us informed of the system's progress in
    serving job seekers with disabilities?
        Answer. The Department will be happy year to continue to
    communicate with Congress on its service delivery strategies and
    initiatives for serving job seekers with disabilities.
                             noncompetitive grants
        Question. Over the past 3 years there have been reports by the
    General Accountability Office, Congressional Research Service, and the
    Department of Labor Inspector General about the excessive awarding of
    noncompetitive grants during the previous administration. This was the
    subject of my subcommittee hearing last September and at several
    previous Appropriations subcommittee hearings. Congress followed-up by
    writing language into the Labor HHS appropriations bill to require
    competitive grant making.
        What will be the Department's approach to noncompetitive grants
    under your leadership?
        Answer. The Department of Labor embraces the value of the
    competitive grant making process as the best vehicle through which to
    select those entities most qualified to carry out its discretionary
    grant programs effectively. We plan to carefully review each request
    for renewal of noncompetitive awards provided under the last
    administration through the Department's published guidance regarding
    competitive exceptions, with an eye to increasing the use of
    competitive grants.
        The Department will comply with the Federal Grant and Cooperative
    Agreement Act, but also recognizes the occasional need to apply legal
    exceptions to its general competitive award policy to achieve specific
    program benefits. In such instances, the Department has established and
    implemented a management process to review proposed exceptions to
    competitive procedures for grants and contracts to ensure that they are
    fully justified. Specifically, a Procurement Review Board, consisting
    of senior staff from four agencies, reviews the proposed noncompetitive
    actions and makes a recommendation to the Chief Acquisition Officer for
    final disposition.
        The Department of Labor is also committed to the principles
    identified in the President's March 4, 2009 memorandum to agencies
    regarding the use of contracts, and will seek to improve the
    effectiveness of acquisition practices and the results achieved from
    contracts by maximizing the use of competition where appropriate.
                         wia dislocated workers formula
        Question. As we discussed at the hearing, I share the concern of
    other members about the 2009 WIA Dislocated Worker funding distribution
    that, because of the formula factors, meant that some States that are
    hurting the most saw a reduction in their funds. While Congress
    considers how to remedy this issue in reauthorization, these States
    will need relief. One of the purposes of the National Emergency Grants
    (NEG) under WIA is to address situations like this.
        I appreciate your support on this issue, and I want to be clear on
    your intent to use some of the NEG funds you received through ARRA and
    fiscal year 2009 appropriations for this purpose.
        Do you plan to use NEG funds to help States who have a high rate of
    unemployment, particularly those greater than the national average, and
    who have received less WIA dislocated worker formula funds in the
    fiscal year 2009 distribution compared to the fiscal year 2008
    distribution through no fault of their own? If so, what are your plans
    for doing so, and how soon could States expect to see those funds?
        Answer. While the Department does not plan to provide on a routine
    basis NEGs to States that received less program year 2009 WIA formula
    funds than they did in program year 2008, the Department is prepared to
    provide NEGs when significant worker dislocation events create a need
    that cannot reasonably be expected to be accommodated within the
    ongoing operations of the WIA Dislocated Worker formula program,
    including the discretionary resources available to the States. Once the
    affected States demonstrate significant usage of both their program
    year 2008 WIA Dislocated Worker formula funds and their Recovery Act
    formula allocations, the Department will consider NEG applications to
    temporarily expand service capacity at the State and local levels by
    providing funding assistance in response to significant economic
    events.
        In addition, a new type of NEG was created after the passage of the
    Recovery Act, to address the dynamics associated with this particular
    economic downturn. Based on the extraordinary effect that the economic
    downturn has had on the labor market and available re-employment
    resources, requests can be made for NEG funds to replenish WIA
    Dislocated Worker formula funds where the applicant has spent 95
    percent of both their current program year and Recovery Act Dislocated
    Worker formula funds. In the event that a State or local area is nearly
    out of WIA Dislocated Worker formula funds, this type of NEG can be
    used to provide the same services available under a State or local
    area's WIA Dislocated Worker formula program until additional WIA
    Dislocated Worker formula resources are made available.
        Question. After reviewing the amount of funds you need to provide
    temporary relief to these States and ensuring you have funds in reserve
    for unexpected layoffs or disasters, please inform the Senate
    Appropriations Committee if you need additional funds and how much.
        Answer. The Department believes with the combination of fiscal year
    2009 National Reserve and Recovery Act resources, adequate funding is
    available to support the use of NEGs as described above. We would also
    appreciate the support of the Committee for the increase of $71 million
    that is requested in fiscal year 2010 for the Dislocated Worker
    National Reserve, as these resources will be critical to meeting the
    needs of dislocated workers into the subsequent program year.
                                     ______

                Questions Submitted by Senator Richard J. Durbin
                             farm labor conditions
        Question. How do you consider farm labor conditions in the United
    States? The Department of Labor has not been very engaged in the issues
    associated with farm labor. What do you see as the Department of
    Labor's role moving forward?
        Answer. Although conditions may have improved for some agricultural
    workers, these workers continue to be among the most vulnerable in the
    workforce. According to a 2008 United States Department of Agriculture
    (USDA) report (Kandel, W. ``Profile of Hired Farmworkers, A 2008
    Update.'' USDA, ERS Economic Research Report No. 60, July, 2008. (38)),
    farmworkers remain ``among the most economically disadvantaged working
    groups in the United States.'' and ``poverty among farmworkers is more
    than double that of all wage and salary employees.'' The report goes on
    to note that not only do farmworkers face workplace hazards similar to
    those found in other industrial settings, they confront a number of
    additional hazards, such as pesticide exposure, sun exposure,
    inadequate sanitary facilities, and crowded and/or substandard housing.
        Being from the State of California, I have a personal interest in
    ensuring that this Department does all it can do to protect the welfare
    of those workers who plant our crops, harvest our vegetables, and put
    food on the tables of homes across this country. The President's fiscal
    year 2010 budget request for the Department's Wage and Hour Division
    will enable that agency to restore its investigator levels to those
    seen prior to 2001. These new investigators will support our goal of
    increasing compliance with and strengthening enforcement of the labor
    standards that protect vulnerable workers and in particular,
    farmworkers. Coupled with this emphasis on vigorous enforcement, the
    Wage and Hour Division will continue its outreach efforts to community
    groups that assist farmworkers, so that those groups can help educate
    agricultural workers about their rights and about their employers'
    obligation to provide a safe and fair workplace for them.
        Our commitment to protecting farmworkers is evidenced by the recent
    action the Department took to ensure that the regulations governing
    worker protections under the Immigration and Nationality Act's H-2A
    temporary nonimmigrant agricultural worker program adequately protect
    the workers in this program. For that reason, on May 29, 2009, we
    announced the suspension of the H-2A regulations promulgated under the
    prior administration effective June 29, 2009. Unfortunately, on June
    29, 2009, the United States District Court for the Middle District of
    North Carolina preliminarily enjoined the suspension.
                         coalition of immokalee workers
        Question. The Coalition of Immokalee Workers (CIW) is a community-
    based organization of mainly Latino, Mayan Indian, and Haitian
    immigrants working in low-wage jobs throughout the State of Florida.
        They organize for the following: a fair wage, better and cheaper
    housing, stronger laws and stronger enforcement against those who would
    violate workers' rights, the right to organize on our jobs without fear
    of retaliation, and an end to indentured servitude in the fields.
        If you are aware of the CIW's efforts to improve conditions in
    Immokalee, can you speak to the market-based, voluntary compliance
    approach--Campaign for Fair Food--spearheaded by the CIW and embraced
    by food industry leaders?
        Answer. The Campaign for Fair Food was initiated in April 2001 when
    the Coalition of Immokalee Workers' farmworkers, who were harvesting
    tomatoes for suppliers of retail food corporations, called for a
    nation-wide consumer boycott of Taco Bell restaurants and products.
    Over the next few years, the campaign was able to obtain agreements
    with large purchasers of tomatoes including Taco Bell, McDonald's, Bon-
    Appetit, Whole Foods Market, and Burger King to improve conditions for
    field workers. These agreements increased the wages by a penny a pound
    and led to additional monitoring of field conditions.
        We understand that the premises of the Campaign for Fair Food are
    that:
      --Retail food corporations have a responsibility to improve the wages
            of farmworkers because their procurement practices have helped
            to suppress those wages at a sub-poverty level.
      --Farmworkers must be full partners with retail food corporations--
            and the growers that supply them--in protecting and advancing
            their own rights (such as the right to overtime and the right
            to organize), as a matter of human dignity and effectiveness in
            changing the conditions in the fields.
      --Consumers have a responsibility to influence retail food
            corporations to ensure the human rights and dignity of the men
            and women harvesting produce through purchasing decisions,
            shareholder actions, and shared public witness.
        The Department applauds all efforts to increase wages and improve
    working conditions for farmworkers and looks forward to working in
    concert with such organizations to further better the lives of the
    laborers that feed families across this country and others.
        Question. I have been working closely with the CIW regarding the
    conditions found on tomato farms in Florida. Would you be willing to
    look further into the situation in Immokalee, Florida?
        Answer. I will review the conditions in Florida and the Department
    will investigate as appropriate.

                               SUBCOMMITEE RECESS

        Senator Harkin. Thank you very much, Madam Secretary.
        The subcommittee will stand recessed.
        [Whereupon, at 10:39 a.m., Wednesday, May 13, the subcom-
    mittee was recessed, to reconvene subject to the call of the
    Chair.]

      DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES, AND EDUCATION, AND
              RELATED AGENCIES APPROPRIATIONS FOR FISCAL YEAR 2010

                                  ----------

                             THURSDAY, MAY 21, 2009

                                           U.S. Senate,
               Subcommittee of the Committee on Appropriations,
                                                        Washington, DC.
        The subcommittee met at 10:29 a.m., in room SD-138, Dirksen
    Senate Office Building, Hon. Tom Harkin (chairman) presiding.
        Present: Senators Harkin and Shelby.

                    DEPARTMENT OF HEALTH AND HUMAN SERVICES

                         National Institutes of Health

    STATEMENT OF RAYNARD S. KINGTON, M.D., Ph.D., ACTING
                DIRECTOR, NATIONAL INSTITUTES OF HEALTH
    ACCOMPANIED BY:
            JOHN E. NIEDERHUBER, M.D., DIRECTOR, NATIONAL CANCER INSTITUTE
            ELIZABETH G. NABEL, M.D., NATIONAL HEART, LUNG, AND BLOOD
                INSTITUTE
            ANTHONY S. FAUCI, M.D., DIRECTOR, NATIONAL INSTITUTE OF ALLERGY
                AND INFECTIOUS DISEASES

                    OPENING STATEMENT OF SENATOR TOM HARKIN

        Senator Harkin. Good morning. The Subcommittee on Labor,
    Health, Human Services, and Education will come to order.
        This morning we will examine the President's proposed
    fiscal year 2010 budget for the National Institutes of Health
    (NIH). We'll also discuss the $10.4 billion that was provided
    for NIH in the Recovery Act.
        I would say at the outset these are exciting times for NIH.
    After several years of stagnant funding, the Recovery Act has
    breathed new life into the field of biomedical research. The
    new Challenge Grant Program alone has generated more than
    20,000 applications from researchers across the country, far
    more than anyone expected.
        The scientific advances that result from this funding will
    probably take some time to gauge but in the meantime, I expect
    it to have a tremendous impact on the economy. Every time a
    researcher gets a grant, it supports an average of six or seven
    jobs. That's not just one researcher by himself or herself.
    It's lab technicians, post-doc fellows and research assistants,
    and then there's the ripple effect of the research itself.
        Maybe this grant leads to a new compound that a
    pharmaceutical company wants to develop into a new drug and
    that means more money in our economy. Maybe an entrepreneur
    uses some breakthrough to form a spin-off company. That
    stimulates the economy, also.
        I just want to note for the record, I don't want any of you
    here at the table to take this wrongly, but all of this money
    won't just go to Bethesda. It goes to researchers in every
    State and it helps the entire country.
        But while there's a great deal of optimism about the next 2
    years, there's also a concern about what happens after the
    Recovery Act funding runs out in the year 2011. After 2 years
    of healthy budgets, will we then have a cliff effect where we
    just kind of fall again?
        That's one of the questions I will want to discuss with our
    witnesses today.
        At this point, I know Senator Cochran is also on our
    Defense Committee hearing mark-up and will probably be here
    later, but I'll leave the record open for his opening statement
    at this point and any other statements that any members of the
    subcommittee might have.
        This morning we have Dr. Raynard S. Kington who was named
    Acting Director of the National Institutes of Health on October
    31 of last year, before that he was Deputy Director for 5 years
    under Dr. Zerhouni.
        Dr. Kington received his B.S. and M.D. degrees from the
    University of Michigan and a Ph.D. from the University of
    Pennsylvania, and I just want to add that, Dr. Kington, I know
    you've served in this capacity probably longer than you thought
    you were going to have to serve. But by every account that I
    have seen, you have done a great job in running this agency and
    I just want to thank you for this period of service and for all
    the previous service, Dr. Kington.
        Also at the table is Dr. Anthony Fauci, the Director of the
    National Institute of Allergy and Infectious Diseases. Again, I
    don't know if you've ever kept count of how many times have you
    appeared before this subcommittee, Tony, going back all these
    years? But again, welcome.
        Dr. Fauci came to NIH in 1968, after completing his
    residency at the New York Hospital, Cornell Medical Center. He
    received his M.D. degree from Cornell University Medical
    College.
        Dr. Elizabeth Nabel is the Director of the National Heart,
    Lung, and Blood Institute, appointed to that position in 2005,
    received her M.D. from Cornell University Medical College, and
    prior to coming to NIH, Dr. Nabel was the Chief of Cardiology
    and Director of the Cardiovascular Research Center at the
    University of Michigan.
        Dr. John Niederhuber is the Director of the National Cancer
    Institute, a graduate of Bethany College in West Virginia,
    received his medical degree from Ohio State, and prior to
    coming to NIH, Dr. Niederhuber was a Professor of Surgery and
    Oncology at the University of Wisconsin School of Medicine.
        I know other Directors are here this morning. Dr. Lawrence
    Tabak at the National Institute of Dental and Craniofacial
    Research is here. Dr. Tabak is here.
        Dr. John Ruffin from the National Center on Minority Health
    and Health Disparities.
        Dr. Steven Katz, the National Institute of Arthritis and
    Musculoskeletal and Skin Diseases, Dr. Katz is here, yes.
        Dr. Story Landis of the National Institute of Neurological
    Diseases and Stroke, Dr. Landis.
        Dr. Richard Hodes, National Institute of Aging. Nice to see
    you again.
        Dr. Griffin Rodgers from the National Institute of Diabetes
    and Digestive and Kidney Diseases, NIDDK.
        And Dr. Thomas Insel, National Institute of Mental Health,
    also here, too.
        Thank you all for being here.
        Now, I had a series of really wonderful hearings last year
    where we brought down something like three directors at a time,
    and I wanted to do that this year, but because of healthcare
    reform that we're working on and I also wear another hat, we're
    trying to get the reauthorization of the Child Nutrition bill
    through, so there's just a lot of things piled up on us right
    now, so I don't have that luxury.
        I think it's very important that we hear from the Directors
    of these Institutes in a more indepth session. I will just say,
    Dr. Kington, it's my intent, consistent with what we have to do
    here in the Senate this year, that maybe we can catch up on
    this later on. I'm still hopeful that maybe this fall some
    time, if we get our healthcare reform bill through and we have
    a little bit more time I would come back and hopefully revisit
    that and reprise what we did again last year.
        I just don't have the time to do it now, but sometime this
    fall. So I say to you and the other directors it is my intent
    to do that. Okay?
        Well, with that, Dr. Kington, we'll turn to you for your
    statement. I just would say that all of your statements will be
    made a part of the record in their entirety and if you'd just
    summarize them in 5 minutes or so, I'd certainly appreciate it.
        Dr. Kington.

                  SUMMARY STATEMENT OF DR. RAYNARD S. KINGTON

        Dr. Kington. Thank you. Mr. Chairman, it's a privilege to
    appear before you today to present the National Institutes of
    Health budget request and to discuss the priorities of NIH for
    fiscal year 2010 and beyond.
        Again, I would like to thank all of my colleagues whom
    you've noted who are here joining me today and we would welcome
    the opportunity to come back and have further discussions
    whenever it is convenient.
        First, I want to express my gratitude to Congress and the
    president for the support reflected in the recent appropriation
    of $10.4 billion in the American Recovery and Reinvestment Act
    (ARRA) for NIH expenditure and the 3.2 percent increase in the
    annual fiscal year 2009 appropriations for NIH.
        The continued trust that you place in the NIH to make the
    discoveries that will lead to better health for everyone is
    appreciated.
        I thank you on behalf of the many scientists who we are
    able to support and more than 3,000 research institutions
    throughout the United States and on behalf of the public who
    count on our research to help detect, treat and prevent
    hundreds of diseases and conditions.
        As noted, I have submitted my testimony for the record and
    will just highlight key points for you now.

                        FISCAL YEAR 2010 BUDGET REQUEST

        The budget request embodies the President's fundamental
    goal of increasing overall Federal investment in biomedical
    research as well as the President's particular emphasis on
    accelerating research in the areas of cancer and autism in
    fiscal year 2010.
        The budget request provides $31 billion, an increase of
    $443 million or 1.4 percent over fiscal year 2009, to help fill
    in gaps in our fundamental understanding of health and disease.
    This request will increase funding for research project grants
    by $243 million.
        The request supports an estimated 9,849 new and competing
    research project grants, about the same level as in fiscal year
    2009, which will provide a success rate in 2010 of about 20
    percent.
        The fiscal year 2010 President's budget request includes
    the following priorities. For cancer research, an increase of
    investment across the NIH to over $6 billion reflecting the
    first year of an 8-year strategy to double cancer research by
    fiscal year 2017. This request represents an increase of $268
    million or 5 percent over an estimated fiscal year 2009.
        For autism research, the NIH will contribute $141 million
    of the $211 million department-wide initiative on autism.
    Working with the Centers for Disease Control and Prevention and
    the Health Resources Service Administration, we will use these
    funds to support research into the causes of and treatment for
    autism spectrum disorders. For NIH this represents an increase
    of $19 million or about 16 percent above the estimated fiscal
    year 2009 level.

                    ECONOMIC AND SCIENTIFIC BENEFITS OF ARRA

        I expressed earlier my gratitude to the President and
    Congress for their support of the NIH with ARRA. It is time
    that the ARRA funds be provided to NIH to stimulate the economy
    and advance biomedical and behavioral research. The biomedical
    research community is not spared from the recent downturn in
    the economy. This is worrisome not only because it means fewer
    jobs but also because innovation and a constant influx of young
    talent are crucial to the Nation's economic success and a
    robust biomedical research enterprise.
        We are moving quickly to identify the best science and
    support it with an additional $10.4 billion provided by ARRA to
    NIH and to obligate it within the next 2 years. We have already
    started selecting projects to receive the funding. To date NIH
    has begun obligating more than $375 million worth of ARRA
    support to a wide array of important projects. We expect the
    number of actions to increase exponentially over the coming
    weeks and months.
        For example, NIH ARRA funding is already supporting
    research to construct a reference sequence dataset for the
    Human Microbiome Project. This genomic survey project promises
    to lay the foundation for future advances to understand the
    impact that microbes in the human body have on health and
    disease.
        Another funded project seeks to develop molecular targeting
    to improve the delivery and efficacy of treatments for deadly
    brain tumors known as glial blastomas.
        Still another ARRA grant will support a Pittsburgh lab that
    has been developing a minimally invasive surgical approach for
    removing intracerebral hematomas, deadly bruises on the brain.
    In this case ARRA funds have allowed the lab to reopen and the
    staff newly returned to their benches to continue their
    potentially life-saving studies.
        Furthermore, your funding decisions sent a strong message
    to scientists in the field and to bright young people who may
    one day choose a career as scientists that the United States is
    working to support outstanding research and outstanding
    scientists.
        Just yesterday the Baltimore Sun published a story on the
    impact of ARRA funding and here's a quote from the article:

        ``There are a lot of really good ideas that were dying on
    the vine because they weren't getting funding,'' said James
    Hughes, Vice President for Research and Development at the
    University of Maryland, Baltimore, ``but with the stimulus
    money, Hughes estimates that his medical, pharmacy, dental, and
    nursing schools could see as much as an additional $100 million
    over the next 2 years, money that will not only further
    research but would create hundreds of good jobs.''

        I am certain that similar scenarios are occurring
    throughout the country and will continue to do so over the next
    2 years as we implement this act. Here's only a sampling of the
    important work that we will support with the ARRA funds.
        For example, we will expand our current understanding of a
    wide array of diseases and conditions, including diabetes,
    various forms of cancer, addiction, glaucoma, infectious
    diseases, heart and lung diseases, arthritis, kidney disease
    and mental disorders.
        In addition, we will expand our efforts in community-based
    research with special focus on minority and under-served
    populations, and make further investments into the potential
    applications of nano technology.
        Just to review briefly, the ARRA funding to NIH will be
    used in the following ways. The legislation allocated $1.3
    billion for the National Center for Research Resources with $1
    billion identified for extramural construction and renovation
    and $300 million targeted for shared instrumentation and other
    large capital research equipment.
        The positive impact of the support for institutions and
    researchers will be extraordinary, providing broader access to
    the state of our equipment. Funding for extramural construction
    and renovation will result in jobs in construction and a number
    of trades in the building industry.
        Shared instrumentation will improve the quality and even
    the speed of work that is done and build collaboration in ways
    that will accelerate discovery. Shared scientific
    instrumentation, including such resources as advanced real-time
    imaging tools, will allow scientists to image the brain in
    action in ways that have not been possible before.
        You appropriated $8.2 billion to NIH, of which $7.4 billion
    was distributed through the Office of the Director to
    Institutes and Centers of NIH and to the common fund for the
    direct support of biomedical research. The remaining $800
    million was distributed by the Office of the Director to fund
    specific research challenges of scientific priorities at the
    Institutes and Centers.
        Our current projections are that NIH activities with these
    funds will support more than 7,000 new awards, most of which
    will be for 2 years of scientific research.
        In addition, $400 million transferred to NIH from the
    Agency for Healthcare Research and Quality as directed under
    ARRA and will be used to support comparative effectiveness
    research. The remaining $500 million will be used to fund high-
    priority repairs, improvements, and construction on the NIH
    Bethesda campus to enable the highest-quality research to be
    conducted.
        Let me review how NIH will be using ARRA dollars in direct
    support of science.
        NIH developed a nimble approach to investing the money
    quickly and with the greatest impact. For example, we are in
    the process of scrutinizing approximately 14,000 grant
    applications we received in our last round of review,
    applications that were already highly meritorious and approved
    by advisory councils at each Institute and Center, applications
    that despite their merit we could not fund before.
        We are now identifying and planning to fund some of these
    scientifically meritorious applications for 2 years where the
    scientific plan is appropriate for a 2-year award instead of
    the usual 4-year award.
        NIH has already issued a number of new funding
    announcements. In particular, we've made targeted grant
    announcements to stimulate research in high-priority exempt
    areas. An excellent example is research funding opportunities
    related to autism, a disease that affects so many families
    across the United States.
        NIH has committed $60 million of research funding, in
    addition to a $141 million in the base budget request, to
    address the differences across autism spectrum disorders.
    Resources will help develop and test diagnostic screening
    tools, assess risk for exposures, test early interventions and
    adapt existing pediatric treatments for older groups with
    autism spectrum disorders.
        While few trials can be completed in 2 years, the ARRA
    funds will be important for jumpstarting projects and building
    the foundation for longer-term autism research.
        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 Nation.
        For example, we've introduced the Challenge Grants, the
    Grant Opportunity or GO Grants, Signature Initiatives, a
    program to encourage the recruitment of new faculty to conduct
    research, and a program to hire students and science teachers
    to work in research laboratories.
        For the Challenge Grants, we issued the largest request for
    applications in NIH history, which is saying something, to
    initiate the program. The 220-page solicitation lists 237
    scientific topics in 15 broad scientific areas. As noted, we
    initially expected to devote approximately $200 million to this
    effort, funding the best proposals from a pool of around
    15,000, we initially estimated. However, upon receiving well
    over 20,000 applications, we now anticipate devoting
    substantially more than that.
        The magnitude of the response demonstrates the breadth and
    depth of the scientific capacity that exists across the United
    States, capacity awaiting only financial support to be
    actualized. It is inspiring to witness the scope and creativity
    of American scientists.
        Here are only a few examples of Challenge Grant topics. New
    advances in biosensors and lab on a chip technology to create
    novel ways to measure the health effects of contaminants in the
    environment and develop high-tech blood and tissue analysis
    techniques, new approaches to better understand persistent HIV-
    1 infections in patients receiving antiretroviral therapy, and
    enhancing research in the bioethics field.
        Another new program is the Grant Opportunity Program or GO
    Grants. The GO Grant Program which was designed to complement
    the Challenge Grants will support large-scale research
    projects. These large-scale projects will accelerate critical
    breakthroughs early in applied research on cutting edge
    technologies and new approaches to improve the interactions
    among multidisciplinary, interdisciplinary research teams. The
    applications are due on May 29th of this year and I know that
    we've received already more than 2,400 letters of intent from
    potential applicants.
        NIH is also identifying a number of Signature Initiatives
    that will support exceptionally creative and innovative
    projects and programs to address major challenges in biomedical
    research in public health. The initiatives will cover new
    scientific opportunities in nano technology, genome-wide
    association studies, health disparities, arthritis, diabetes,
    autism, genetic risk for Alzheimer's disease, regenerative
    medicine, oral fluids as biomarkers, and HIV vaccine research.
        In addition to direct support from the Institutes and
    Centers ARRA funds, the Office of The Director will also
    support at least $30 million from its ARRA funds for these
    signature projects.
        We've also announced a 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, provide
    appropriate start-up packages, and develop pilot research
    projects for newly independent investigators. The applications
    for this program are due to NIH May 29, as well.
        We are particularly delighted to tell you about our
    expanded summer program for teachers and students from all 50
    States and the District of Columbia. NIH will use $35 million
    of ARRA dollars to support short-term jobs over 2 summers for
    over 3,700 individuals. Most of these will be high school and
    undergraduate students, though the number also includes several
    hundred elementary, middle, high school, and community college
    science educators.
        This laboratory experience around the country will provide
    several thousand Americans with the opportunity to experience
    the extraordinary world of research. We hope this experience
    will spark the desire of many of these students 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 to
    increase 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
    very 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 analysis. To track all of
    the 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 early diagnoses, better treatments and other public
    health improvements expected by Congress and the American
    public.
        Because of the ARRA funds, there will be more discoveries
    across the country next year and many years thereafter. These
    findings will yield better understanding of the major diseases
    and disorders, including those I touched on today, and hundreds
    more, as well as providing keys to living healthier lives.
        As I said in my opening comments, we are grateful for the
    commitment to biomedical research and all the promise it brings
    to the 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 still stimulate the economy,
    create jobs and advance science.
        Most importantly, however, ARRA will help contribute to our
    principal mission: to make scientific discoveries that will
    improve people's health.

                              PREPARED STATEMENTS

        I will be pleased to answer any questions that you might
    have.
        [The statements follow:]
                    Prepared Statement of Raynard S. Kington
        Good morning, Mr. Chairman and distinguished members of the
    subcommittee.
        It is a privilege for me to appear before you today to present the
    National Institutes of Health (NIH) budget request and to discuss the
    priorities of NIH for fiscal year 2010 and beyond.
        First, I want to express our gratitude for your and the President's
    support as reflected in the recent appropriation of $10.4 billion in
    the American Recovery and Reinvestment Act (ARRA) for NIH expenditure
    and the 3.2 percent increase in annual fiscal year 2009 appropriations
    for NIH. The continued trust that you place in NIH to make the
    discoveries that will lead to better health for everyone is
    appreciated.
        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
    United States territories; and on behalf of the public, who count on
    our research to help detect, treat, or prevent hundreds of diseases and
    conditions.
        As you well know, research conducted and supported by the NIH
    touches people's lives every day. NIH is the largest single engine for
    outstanding biomedical research in this country--and the world. Not
    only does NIH have an impact globally, it also has a lasting impact at
    the community level, bringing intellectual and economic growth to towns
    and cities across America.
    Fiscal Year 2010 Budget Request
        The budget request embodies the President's fundamental goal of
    increasing overall Federal investment in basic research and development
    as well as particular emphasis on accelerating research in the areas of
    cancer and autism in fiscal year 2010.
        The budget request provides $31 billion, an increase of $443
    million or 1.4 percent over fiscal year 2009, to help fill gaps in our
    fundamental understanding of health and disease. NIH Research Project
    Grants (RPGs) support scientists to discover the fundamental
    underpinnings of complex human biology through investigator-initiated
    research, the mainstay of creativity in science. This request will
    increase funding for RPGs by $243 million. The request supports an
    estimated 9,849 new and competing RPGs, about the same level as fiscal
    year 2009.
        The fiscal year 2010 President's budget request includes the
    following priorities:
        Cancer Research.--Increases the investment across NIH to over $6
    billion for cancer research across NIH, reflecting the first year of an
    8-year strategy to double cancer research by fiscal year 2017. The
    fiscal year 2010 request represents an increase of $268 million or 5
    percent over the estimated fiscal year 2009 level.
        Autism Research.--Invests $141 million of the $211 million
    Department-wide initiative on autism. This total amount includes the
    Centers for Disease Control and Prevention and Health Resources
    Services Administration for research into the causes of and treatments
    for autism spectrum disorders. For NIH, this represents an increase of
    $19 million or 16 percent above the estimated fiscal year 2009 level.
    Economic and Scientific Benefits of ARRA
        I expressed earlier my gratitude to the President and Congress for
    their support of NIH with ARRA. It is timely that ARRA funds be
    provided to the NIH to stimulate the economy and advance biomedical and
    behavioral research. The biomedical research community has not been
    spared from the drastic downturn in the economy. This is worrisome not
    only because it means fewer jobs, but also because innovation and a
    constant influx of young talent are crucial to the Nation's economic
    success and a robust biomedical research enterprise.
        We are moving quickly to identify the best science and support it
    with the additional $10.4 billion provided by ARRA to the NIH, and
    obligate it within the next 2 years. Moreover, your decision sends a
    strong signal to the scientists in the field, and to bright young
    people who may one day choose science as a career, that the United
    States is working to support outstanding research and outstanding
    scientists.
        To demonstrate the impact ARRA will have at the individual level, I
    would like to share with you the following: One of our program
    directors received an email after enactment of ARRA in response to news
    that an applicant's grant application was being considered for funding
    with ARRA money.
        Here is an excerpt from the email (with names deleted):

        ``Forgot to say that we gave a termination letter last Friday to my
    longtime (5 years) postdoc. His job has been saved. He is going to be
    thrilled to hear about his change in fortune! I also would like to hire
    a technician with the new funds, since at present I do not have one.''

        Let me highlight some of the important work that we will support
    with ARRA funds. For example, we will rapidly expand our current
    understanding of the genetic changes associated with a wide range of
    diseases and conditions, including addiction, Alzheimer's disease,
    various forms of cancer, chronic pain, diabetes, glaucoma, heart and
    lung diseases, kidney disease, and mental disorders, through genetic
    analysis of existing, well characterized population cohorts. We will
    take steps toward using this genetic information to better inform the
    modification of disease for those patients most at risk, principally
    through lifestyle factors and personal health behaviors.
        In addition, our efforts to expand community-based research
    efforts, with special focus on minority and underserved patients, will
    be accelerated through catalytic grants designed to enhance
    interrelationships among academic health centers, community
    organizations, and community healthcare clinical centers. Evaluation of
    the health and safety risks of nanoscale products is critical as
    nanomaterials are being used in applications as diverse as medical
    devices, drug delivery, cosmetics, and textiles. Biological, physical,
    and chemical characterization of selected nanomaterials will be
    conducted to both inform the establishment of standards for health and
    safety and developing computational models for the prediction of long-
    term secondary effects.
        Just to review briefly, the ARRA provided NIH funding in the
    following ways:
      --It allocated $1.3 billion for the National Center for Research
            Resources, with $1 billion identified for extramural
            construction and renovation, and $300 million targeted for
            shared instrumentation and other large capital research
            equipment. The positive impact of this support for institutions
            and researchers will be extraordinary, providing broader access
            to state-of-the-art equipment. Funding for extramural
            construction and renovation will result in jobs in construction
            and a number of trades in the building industry. Shared
            instrumentation will improve the quality and even the speed of
            the work that is done, and build collaboration in ways that
            will accelerate discovery. Shared instrumentation, including
            such resources as advanced real-time imaging tools, will allow
            scientists to image the brain in action or enable them to see
            separate proteins that play a role in health and disease.
      --It appropriated $8.2 billion to NIH, of which $7.4 billion will be
            distributed through the NIH Office of the Director, to the
            Institutes and Centers of NIH, and to the common fund for the
            support of biomedical research. The remaining $800 million will
            be distributed by the Office of the Director to fund specific
            challenges and scientific priorities at the Institutes and
            Centers.
      --In addition, $400 million transferred to NIH by the Agency for
            Healthcare Research and Quality (AHRQ), as directed under ARRA,
            will be used to support comparative effectiveness research.
      --The remaining $500 million will be used to fund high-priority
            repairs, improvements, and construction on the NIH campus to
            enable the highest quality research to be conducted.
    How Will NIH Accomplish This Task
        NIH is determined to seize the opportunity afforded by the infusion
    of ARRA resources to develop a nimble approach to investing the money
    quickly with the greatest impact. This opportunity is too important for
    us to conduct ``business as usual.'' It demands that we employ the best
    possible approaches to ensure progress at in an accelerated pace, with
    the most efficient and effective use of resources. For example, we are
    scrutinizing the 14,000 grant applications we received in our last
    round of review--applications that were already deemed highly
    meritorious and approved by Advisory Councils at each Institute and
    Center--applications that, despite their merit, we could not fund
    before. We are now starting to fund those scientifically meritorious
    applications for 2 years, where the scientific plan is appropriate for
    a 2-year award instead of the usual 4-year award. Also, every Institute
    and Center is identifying scientific priorities that can be funded
    through administrative supplements. Administrative supplements will
    accelerate the progress of a promising grant, typically by adding
    support for postdoctoral scientists and graduate students and key
    pieces of equipment
        The NIH team is proud of the trust placed in it to be a part of the
    economic recovery process. NIH will work tirelessly to support the
    goals and intent of ARRA, with wise resource investments in science.
        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 Nation. For example, NIH created a new
    program called the Challenge Grant award. To jump start this program,
    we issued the largest Request for Applications in our history. This
    220-page document lists numerous scientific topics in 15 broad
    scientific areas, including: bioethics, translational science,
    genomics, health disparities, enhancing clinical trials, behavioral
    change and prevention, and regenerative medicine--areas that would
    benefit from a jumpstart or in which a scientific challenge needs to be
    overcome. The Office of the Director expects to devote at least $200
    million of these funds to this effort.
        I will highlight only a few examples of the Challenge Grant topics
    that could be further explored:
      --New advances in biosensors and lab-on-chip technology to create
            novel ways to measure the body burden and sub-clinical health
            effects of emerging contaminants in the environment in large
            study populations. Additional research funds could support
            field testing of the most promising sensors and analysis
            techniques through collaboration with existing epidemiologic
            studies taking advantage of both new and banked tissue
            specimens.
      --There is increasing evidence that suggests that HIV-1 infected
            individuals experience similar immunologic changes as the
            uninfected elderly. This may be due to persistent stimulation
            of the immune cells. It is not clear whether antiretroviral
            therapy can reverse this process. Research will aim to compare
            the effectiveness of different treatment regimens in reversing
            or preventing accelerated aging that appears in the immune and
            other body systems.
      --Studies are needed to assess the impact and ethical considerations
            of conducting biomedical and clinical research internationally
            in resource-limited countries.
        Another new program is what we call the Grand Opportunity Program,
    or ``GO grants.'' The purpose of this program is to support high-impact
    ideas that require significant resources for a discrete period of time
    to lay the foundation for new fields of investigation. The GO program
    will support large-scale research projects that accelerate critical
    breakthroughs, early and applied research on cutting-edge technologies,
    and new approaches to improve the synergy and interactions among
    multidisciplinary and interdisciplinary research teams. Applicants may
    propose to address either a specific research question or propose the
    creation of a unique infrastructure/resource designed to accelerate
    scientific progress. For those projects that span the missions of
    multiple Institutes, Centers, and Offices (ICs), support may come from
    ARRA funds allocated to the Common Fund.
        NIH will identify a number of signature initiatives that will
    support exceptionally creative and innovative projects and programs--
    and potentially transformative approaches to major challenges in
    biomedical research. The initiatives will cover new scientific
    opportunities in nanotechnology, genome-wide association studies,
    health disparities, arthritis, diabetes, autism, and the genetic risk
    for Alzheimer's disease, regenerative medicine, oral fluids as
    biomarkers, and HIV vaccine research.
        Each IC is developing at least one signature initiative, and a
    number will be done in partnership across ICs and/or the Office of the
    NIH Director. The areas being developed include an Office of the
    Director-led set of catalytic awards to enhance community-based
    research efforts to ensure that we are able to reach segments of our
    Nation that are too often overlooked in clinical research.
        In addition, considerable investment is expected to be made to
    understand the genetics of a wide range of specific diseases and
    conditions, as well as second generation ``deep DNA sequencing'' of
    very large and well-defined national patient cohorts to identify
    disease causing genetic variants. Using new technology developed with
    NIH-support, ``deep sequencing'' allows analysis of genome sequence
    from many individuals to provide greater insight about subtle genetic
    variations than could previous methods, and does so at lower cost.'' An
    initiative to modify disease risk-based on genome-wide association
    findings is also being planned. Complementing this will be initiatives
    to accelerate biomarker discovery and validation.
        Also, NIH will use other funding mechanisms, such as the Academic
    Research Enhancement Award, or AREA grants, that support small research
    projects in the biomedical and behavioral sciences conducted by faculty
    and students in health professional schools and other academic
    components that have not been major recipients of NIH research grant
    funds. A research program to support new faculty, called the ``Core
    Centers for Enhancing Research Capacity in U.S. Academic
    Institutions,'' will address the need for more bioethicists and provide
    opportunities for young scientists, who are one of NIH's top priorities
    for support. The Core Center grants are designed to establish
    innovative programs of excellence by providing scientific and
    programmatic support for research by promising investigators. They
    provide funding to hire, provide appropriate start-up packages, and
    develop pilot research projects for newly independent investigators,
    with the goal of augmenting and expanding the institution's biomedical
    research base. We must invest today to ensure tomorrow's scientific
    discoveries.
    ARRA Funds for Administrative Supplements
        U.S. institutions and investigators with active NIH research grants
    may request administrative supplements for the purpose of accelerating
    the pace of scientific research through the programs and activities of
    their peer-reviewed projects. These supplements seek to promote job
    creation and retention, as well as scientific progress at NIH-funded
    institutions, by providing researchers with the means to employ, for
    example, postgraduate students or to enhance capacity for data
    analysis.
        We are particularly delighted to tell you about our expanded summer
    program for teachers and students across America. Funds will provide
    short-term summer jobs for high school and undergraduate students--as
    well as elementary, middle, high school and community college science
    educators in laboratories around the country--work that will not only
    provide summer income, but will also provide several thousand young
    people with the opportunity to experience the world of research, and I
    hope will spark their desire to become scientists.
        In addition to administrative supplements, U.S. research
    institutions and scientists with active NIH Research Grants may submit
    revision applications (so-called ``competitive supplements'') to
    support a significant expansion of the scope or research protocol of
    currently approved and funded projects.
    The Economic Benefits
        We are mindful that a top priority for the use of ARRA funds by NIH
    is to create and preserve jobs, as well as increase 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. In keeping with
    the ARRA reporting requirements, we are asking recipients to document
    key economic benefits, such as jobs created and retained. A study
    indicates that, on average, every NIH grant supports 6 to 7 in-part or
    full scientific jobs.\1\ Another study suggests that every dollar spent
    by NIH in local communities around the Nation is leveraged on average
    three times its original amount, if you look at the national ``economic
    multiplier'' effect.\2\ These grants pay the salaries of scientists and
    technicians. The scientists and technicians, in turn, purchase goods
    and services in the communities in which they work and live.
    ---------------------------------------------------------------------------
        \1\ ``Estimating the Number of Senior/Key Personnel Engaged in NIH
    Supported Research,'' study issued October 2008. Study funded by the
    NIH Evaluation Set-Aside Program, 07-5002-OD-ORIS-OER, administered by
    the Evaluation Branch, Division of Evaluation and Systematic
    Assessment, OPASI, Office of the Director, National Institutes of
    Health.
        \2\ ``In Your Own Backyard: How NIH Funding Helps Your State's
    Economy,'' published by Family USA (A Global Health Initiative Report).
    June 2008.
    ---------------------------------------------------------------------------
    ARRA: Risk Management
        NIH has implemented a risk management program in compliance with
    OMB guidelines that addresses the identification and assessment of
    proper controls over financial reporting and operations processes. In
    the financial arena, the risk program includes reviews of financial
    reporting at the transaction level that are conducted by both internal
    and external auditors. In the operations arena, the program includes
    internal assessments of systems and processes that support both
    intramural and extramural research.
    The Scientific Benefits
        The advancement of science is a gradual process. Groundbreaking
    discoveries are most often built on the foundation of many gradual
    advances that bring us closer to diagnosis, treatments, and other
    public health improvements expected by Congress and the American
    public. Because of ARRA funds, there may be many such discoveries
    across the country next year and many years thereafter. These
    discoveries could yield better understanding of the major diseases and
    disorders such as heart disease, cancer, neurodegenerative illnesses,
    autism, arthritis, mental health, chronic, acute and rare diseases, and
    diseases related to addiction or behavior.
        We are committed to ensuring that ARRA funds will produce benefits
    to the economy, to scientific knowledge, and ultimately aid in
    improving the health of the Nation. As an agency, we are well-equipped
    to disburse these resources, to handle the increase in workload, and
    award grants expeditiously to the best scientists in the world.
        Again, NIH is grateful for your trust and commitment to biomedical
    research and all the promise 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 provide you
    and the public with regular updates and reports to ensure full
    transparency and accountability for how these funds are being spent.
    Americans deserve to know the impact of their tax dollars--on science,
    on the economy, and the Nation's health. In addition, we look forward
    to working with you on the fiscal year 2010 budget request.
        I would be pleased to answer any questions that you might have.
                                     ______

                   Prepared Statement of John E. Niederhuber
        Mr. Chairman and Members of the subcommittee: Thank you for the
    opportunity to offer testimony on behalf of the National Cancer
    Institute (NCI) and the National Cancer Program.
        I am pleased to present the President's fiscal year 2010 budget
    request for the NCI of the National Institutes of Health (NIH). The
    fiscal year 2010 budget includes $5,150,170,000, which is $181,197,000
    more than the fiscal year 2009 appropriation of $4,968,973,000.
                            doubling cancer research
        The fiscal year 2010 budget reflects the President's prioritization
    of biomedical research supported by NIH. The budget is the first year
    of an 8-year strategy to double the NIH-wide cancer research budget and
    includes over $6 billion for this purpose. The budget balances the
    President's commitment to cancer research with that of research in
    other areas.
        NIH's fiscal year 2010 budget will build upon the unprecedented $10
    billion provided in the American Recovery and Reinvestment Act of 2009,
    which will support new NIH research on a wide array of diseases,
    condition, and disorders in 2009 and 2010.
        Because cancer research involves the dissection and understanding
    of perhaps the most basic functions of human cell growth and
    differentiation, cancer research will always produce many serendipitous
    discoveries. Such discoveries involving the most basic properties of
    human cells have historically contributed to our understanding of the
    basic biology underlying almost all diseases.
        In addition, cancer research also involves technology development
    that will benefit research in a number of disease areas. For example,
    cancer research includes a major effort to understand the complete
    genetic alterations that result in abnormal cell growth. This effort in
    whole genome sequencing is a major driver in the development of
    sequencing technology that we believe will lead to our ability in the
    next 2-3 years to perform whole genome sequencing in a matter of hours
    for less than $1,000.
        Numerous other Institutes and Centers contribute their expertise to
    fundamental research on biological processes, technologies and tools,
    and work collaboratively with NCI to fund important research in cancer.
    For example, much of what has been learned at NCI in controlling
    tobacco usage is now being applied to study and address the growing
    health burden of obesity. NIH will work to ensure that cancer research
    resources are allocated responsibly, effectively, in accordance with
    peer review principles, and on the basis of sound science and cancer
    relevance.
                          moving past a legacy of fear
        One of the great American voices on behalf of biomedical research
    was Mary Lasker. A well-known figure in Washington politics and
    government, Mrs. Lasker was a driving force behind the creation of
    several Institutes of the NIH and a key player in the formulation and
    passage of the National Cancer Act of 1971. Among her towering
    accomplishments, however, one stands out, perhaps because of its
    simplicity. In the years after World War II, cancer, she once remarked,
    remained ``a word you simply could not say out loud.'' Mary Lasker
    changed that. She persuaded David Sarnoff, the powerful head of the
    Radio Corporation of America--RCA--to allow the utterance on the
    airwaves of that single, chilling word.
        Today, we feel no compulsion to avoid speaking its name; yet few
    would argue that we fear cancer less in 2009 than we did 50 or 100
    years ago. Cancer will befall approximately 1 of 2 American men and 1
    of 3 American women. Its diagnosis engenders thoughts of mortality, of
    debilitating treatments, of diminished quality of life, of lingering
    burdens on loved ones, of personal financial peril.
        This major health problem is fueled by an aging, more heterogeneous
    population. A study published in April 2009 by the University of Texas
    M.D. Anderson Cancer Center estimated that the number of new cancer
    cases in the United States each year will increase by 45 percent over
    the next two decades, to 2.3 million per year by 2030.
        It is thus quite understandable when the public and those
    responsible for health care ask if we are investing enough to advance
    the science needed to avert such predictions. Since 1971, the Federal
    Government, private foundations, and companies have spent approximately
    $200 billion on cancer research. This investment has led to our
    understanding of many of cancer's numerous complexities; has resulted
    in a steady decline in the annual overall cancer mortality--and has
    increased the number of cancer survivors to more than 12 million
    Americans. NCI's budget request and its research projects are
    consistent with the President's multi-year commitment for cancer and
    autism. Aggressive programs in screening and prevention have greatly
    reduced the incidence of a number of cancers. For example, NCI led
    efforts to eliminate the use of tobacco has resulted in a 1.9 percent
    decrease per year from 1992 to 2003 in male lung cancer incidence
    rates. This has accelerated to a 3.3 percent decline per year over the
    period from 2003 to 2006. Despite these advances, it is evident that a
    greater investment than ever is needed to continue the dissection of
    the fundamental biology underlying the initiation of abnormal cell
    growth and its progression to invasive and metastatic disease.
                            the power of the genome
        Cancer is an extremely complex disease of altered genes. These
    changes within the cells of our body take many forms--and are both
    inherited and acquired, as we live out our lives. Since the completion
    of the Human Genome Project in 2003, the knowledge of the genetic
    alterations associated with cancer has grown exponentially. Vastly
    improved technologies are making it possible to study the genomes of
    thousands of individuals, in the search for common abnormalities that
    point to risk of cancer. Likewise, one of NCI's signature projects, The
    Cancer Genome Atlas (TCGA), is studying the genetic changes associated
    with the development of several cancer types, including lung, ovarian,
    and brain cancers. The success of this pilot program is leading NCI to
    expand TCGA's scope to the sequencing of 20 to 25 tumor types.
    Sequencing these tumors in more than 200 patients per tumor type,
    coupled with whole genome scans of large population cohorts, is
    uncovering important information about cancer risk and patient-specific
    profiles unique to disease. Within just 5 years, some have suggested,
    whole genome deep sequencing will be part of virtually every laboratory
    cancer experiment, and within a decade, such deep genomic sequencing
    will be commonplace for patients.
        At this moment, the results of this deep probing of the genetic
    basis of cancer remain, in most cases, fascinatingly powerful
    information. How we turn that information--sometimes referred to as
    code--into new methods of prevention, early detection, and treatment of
    cancer will require a major infusion of new resources. We must convert
    this coded information, which is stored in large data sets, into a
    clear interpretation and understanding of the functional biological
    alterations these genetic changes impart. NCI is working to fill this
    large gap in our knowledge, through a well-considered, coordinated
    blueprint appropriate for a new era of medicine. It begins with new
    discoveries at the level of the gene and ends at the patient's bedside.
        NCI is preparing to bring together a network of investigators,
    whose work will begin after genomic sequencing is completed, taking
    information generated by TCGA and allied projects and turning that data
    into new knowledge of biologic function. The goal will be to identify
    potential new therapeutic targets in molecular pathways and physical
    processes that are, today, considered ``undruggable.'' This network
    will be virtual: a consortium of researchers primarily at research
    universities who will be offered the chance to participate in
    collaborative projects, often partnering between institutions. These
    projects will be prioritized on the basis of potential patient impact
    and technical feasibility--assigned to investigator sites on a
    competitive basis, each with a project manager.
        The targets that will come forward from this functional biology
    consortium will be somewhat akin to a key piece of a jigsaw puzzle. It
    will be necessary to find the adjoining pieces--the new drugs,
    biologics, and other therapeutics--that connect. When potential new
    targets emerge, NCI will then employ its state-of-the art, high-
    throughput capacity to screen thousands of previously identified
    compounds, both natural and synthetic, to identify the exact piece to
    complete the puzzle.
        In many cases, new therapies will require refinement, for example,
    to make them water soluble, or to create mass-producible versions of a
    natural product. Another virtual network, the Chemical Biology
    Consortium, will provide the necessary chemistry and chemists to
    optimize further development of these new anti-cancer agents. NCI will
    then be able to have those new agents produced in small batches for
    refinement and testing--using best manufacturing principles--and move
    them into pre-clinical testing, including toxicology screening.
        Early phase clinical trials will follow. NCI has conducted the
    first of a new kind of trial called Phase 0, which uses a small number
    of carefully selected patients who, after receiving small doses of new
    drugs, are studied, in real time, at the molecular level, to see if the
    new medication is reaching and affecting its target. Phase 0 trials
    will allow for significantly earlier decisions on whether to move
    forward with Phase 1 trials.
        It is not only Phase 0 trials that will require well characterized
    patients. As genomic characterization of the populace comes closer to
    becoming standard medical practice, NCI is taking steps on the leading
    edge of that transition, creating the first of a national network of
    patient characterization centers that will centrally conduct genomic
    and genetic characterization. Always employing the latest technologies
    and standardized protocols, these facilities will serve wide geographic
    areas, bringing together genomics and genetics, proteins and
    proteomics, all in the interest of matching a genetically characterized
    patient and his or her characterized tumor to appropriate and optimal
    therapeutic solutions.
        The NIH Clinical Center; NCI's Specialized Programs of Research
    Excellence; the NCI Community Cancer Centers Program; Cooperative
    Groups; the Community Clinical Oncology Program; and the NCI-designated
    Cancer Centers network will all be key players in establishing a highly
    characterized national cohort of patients who can be easily matched
    with potential new agents.
                      developing electronic health records
        Creating an integrated, 21st century translational science program
    will require data integration and a national commitment for the cancer
    electronic health record. NCI's cancer Biomedical Informatics Grid,
    better known as caBIGT, and its companion BIG Health Consortium, are
    leaders in this Federal effort, working to develop a unified biomedical
    information infrastructure, along with data standards and protocols for
    electronic medical records that are consistent with the Federal
    Government's national health IT efforts. Through caBIG, NCI is helping
    both large facilities from the NCI-designated Cancer Centers network
    and local facilities in the NCI Community Cancer Centers Program
    develop electronic records.
        In addition, accomplishing the scale-up of TCGA and the genetic
    characterization of our patients--with data integration through caBIG--
    will require biospecimens collected using standardized protocols,
    tissue characterization, cataloging, and analysis, all coordinated by
    NCI's caHUB initiative.
                             a wide-ranging effort
        This plan will require the contributions of biologists, chemists,
    informaticians, and clinical scientists devoted to a clear path from
    discovery to patient. This is not only the nature of translation; it
    will be a model for the study of many diseases and, ultimately, a model
    of 21st century healthcare. This platform is a vision for a new way of
    thinking. But it is not an unrealistic concept. It is an action plan: a
    roadmap for what we have begun to assemble this year, making the
    optimal use of every new resource.
        In 2008, NCI began a series of meetings with theoretical physicists
    and mathematicians, designed to bring unique perspectives to the
    problem of cancer. The result is a new network of physical sciences--
    oncology centers, soon to launch, which will study physical forces--
    heat, stress, and cellular evolution, just to name a few--in cancer.
    This network is an exciting frontier in cancer research, which we
    fervently believe will be further proof that scientific collaboration
    pays great dividends.
        NCI's goal is to make cancer a chronic condition one can live with,
    and not die from. We will continue to find better ways to prevent
    cancer's development and for the earliest detection, when a tumor is
    limited to a very small number of cells. We will continue to develop
    new therapies with fewer side-effects and greater quality of life. We
    will continue to study environmental causes of cancer. We will continue
    efforts to better understand the behaviors that increase cancer risk,
    and we will continue to follow those who have survived cancer, to
    understand the reasons why they are so often at risk for subsequent
    malignancies. These efforts will require coordinated programs and the
    continued work of a remarkable national cadre of individual laboratory
    investigators.
        NCI is committed to paying dividends on behalf of every American.
    We no longer fear speaking the word cancer. Yet, our work is far from
    finished, and NCI remains committed to making every effort to advance a
    vastly different medical future.
        Thank you for the opportunity to provide you this testimony. I look
    forward to the opportunity to take your questions.
                                     ______

                    Prepared Statement of Elizabeth G. Nabel
        Mr. Chairman and members of the subcommittee: I am pleased to
    present the President's fiscal year 2010 budget request for the
    National Heart, Lung, and Blood Institute (NHLBI) of the National
    Institutes of Health (NIH). The fiscal year 2010 budget of
    $3,050,356,000 includes an increase of $34,667,000 over the fiscal year
    2009 appropriated level of $3,015,689,000.
        The NHLBI provides global leadership for a research and education
    program to promote prevention and treatment of heart, lung, and blood
    diseases. The vision is to enhance the health of all individuals and
    thereby enable them to lead longer and happier lives. The work of
    Institute is guided by the goals and approaches outlined in its
    strategic plan, which was completed and published in September 2007 and
    submits that its research projects re consistent with the President's
    multi-year commitment for cancer and autism.
        This statement describes several initiatives that are being
    undertaken during the current fiscal year and outlines a number of
    opportunities to be addressed in fiscal year 2010.
                              stem cell consortium
        Recent advances in knowledge, coupled with development of new
    technologies and reagents, have set the stage for rapid progress in the
    field of regenerative biology and medicine. The NHLBI is capitalizing
    on this extraordinary opportunity through formation of a Progenitor
    Stem Cell Biology Consortium that includes leading scientists in the
    fields of cardiovascular, pulmonary, and hematopoietic cell biology
    working closely with experts in the general field of progenitor cell
    biology. Its goal is to identify and characterize progenitor cell
    lineages, to direct the differentiation of stem and progenitor cells to
    desired cell fates, and to develop strategies to address the challenges
    presented by the transplantation of such cells. The Institute will fund
    6 research hubs and 1 administrative coordinating center in fiscal year
    2009, with plans for a total support period of 7 years.
              clinical trial of hypertension management strategies
        A new clinical trial, the Systolic Blood Pressure Intervention
    Trial (SPRINT), was launched in fiscal year 2009. The health benefits
    of lowering blood pressure in individuals with hypertension have been
    well demonstrated, and current practice strives to achieve a systolic
    blood pressure (SBP) level below 140 mmHg for most patients. However,
    epidemiological evidence suggests that the optimal SBP goal may be even
    lower. SPRINT will enroll about 7,500 individuals with hypertension or
    pre-hypertension, randomly assign them to a SBP goal of <120 mmHg or
    <140 mmHg, and assess cardiovascular disease outcomes. The potential
    public health impact of this work is substantial, given the multi-
    millions of people in this country and worldwide who suffer from high
    blood pressure.
                                 asthma network
        The NHLBI has for many years supported highly successful clinical
    research networks designed to fill gaps in science and address emerging
    areas of concern in the management of asthma. Upon the anticipated end
    of the current funding period for the asthma networks, the Institute
    convened a workshop to obtain advice from key scientific leaders on a
    network structure that would sustain the past success and meet future
    clinical research needs. As a result of its recommendations, the
    Institute is establishing AsthmaNet, a clinical research network that
    will develop and conduct clinical trials of new treatment and
    management approaches in pediatric and adult populations. Launched in
    fiscal year 2009, AsthmaNet will include multiple clinical centers and
    one data coordinating center. The NHLBI's plans for promoting use of
    shared resources and promoting programmatic and scientific efficiency
    in the network coincide with the expansion of the NIH Roadmap
    initiative to Re-engineer the Clinical Research Enterprise through the
    Clinical and Translational Science Award program.
                         hemoglobinopathies data system
        The NHLBI is developing and implementing a national data system and
    biospecimen repository on people with sickle cell disease, thalassemia,
    and hemoglobin E disease. It will be designed to collect, analyze,
    interpret, and disseminate State-specific data on the epidemiology,
    clinical characteristics, healthcare utilization, and community
    resources of patients with these conditions. The system will support
    research, information dissemination, policy decisions, healthcare
    planning, and provider training at the social, State, and national
    levels. This fiscal year 2009 initiative is being conducted via an
    interagency agreement with the CDC.
         cardiac translational research implementation program (c-trip)
        A new program has been designed to accelerate the movement of
    laboratory discoveries to the bedside of patients with heart failure or
    arrhythmias. C-TRIP is a two-stage project to speed translation of
    promising new therapeutic interventions derived from basic research
    through well-designed clinical trials to demonstrate safety and
    efficacy. Two-year stage 1 exploratory planning grants, to be awarded
    in fiscal year 2010, will support feasibility studies, analysis of
    existing data, preparation for regulatory clearances, team-building,
    development of clinical management tools and recruitment strategies,
    and finalization of protocols. Subsequently, stage 2 grant applications
    will be considered for the conduct of the safety and efficacy trials.
              new programs to prevent and treat childhood obesity
        Obesity is a major cause of morbidity and mortality, and effective
    interventions are urgently needed to address this increasingly
    prevalent public health menace. A new research consortium will test the
    efficacy of innovative approaches to prevent weight gain among normal-
    weight young children and to prevent additional weight gain or
    facilitate weight loss among obese adolescents.
        A second fiscal year 2010 initiative will examine outcomes
    associated with existing community programs designed to reduce
    childhood obesity by improving children's diet and physical activity.
    One research unit will be funded to serve as a study coordinating
    center, which will work with the National Collaborative on Childhood
    Obesity Research to design and implement the research. The study will
    establish common metrics for evaluation of the programs and examine
    outcomes associated with program policies, environments, educational
    activities, dietary and physical activity regimens, and other factors.
    The goal is to inform national and local policy for control of
    childhood obesity.
                resuscitation outcomes consortium (roc) renewal
        In 2004 the NHLBI, the American Heart Association, the U.S.
    Department of Defense, and several Canadian health agencies established
    the ROC to design and conduct studies of promising experimental
    strategies to resuscitate patients who experience out-of-hospital
    cardiac arrest or life-threatening trauma. The ROC brings together
    investigators, hospitals, emergency medical services (EMS), and local
    communities to address the unique characteristics of this research and
    ensure the efficient translation of proven strategies into clinical
    practice. In addition to supporting new trial protocols, the 2010
    renewal will develop information to define and improve pre-hospital
    best practices, facilitate public health efforts for the prevention of
    emergency life-threatening conditions, and improve EMS delivery and
    training.
              prematurity and respiratory outcomes program (prop)
        The new PROP will promote collaborative, innovative research to
    identify mechanisms, and associated biomarkers of respiratory disease
    risk of premature infants who are ready for discharge from the neonatal
    intensive care unit. Increased survival of very premature infants is
    leading to increasing numbers of children with chronic lung disease
    that often results in multiple readmissions. Currently no objective
    measures exist that can be used to predict which premature newborns
    will have persistent respiratory problems after discharge from the
    hospital. This cooperative, multidisciplinary scientific group will
    investigate hypotheses on the molecular mechanisms that make certain
    premature newborns prone to develop recurrent respiratory disease, with
    the long-term goal of improving outcomes in the first year of life.
                          nhlbi proteomics initiative
        The Institute will continue to invest substantial resources in the
    use of proteomic approaches and technologies to develop a greater
    understanding of pathway and interactions that influence heart, lung,
    and blood diseases. Planned for fiscal year 2010 is a combined renewal
    of the NHLBI Proteomic Centers and the NHLBI Clinical Proteomic
    Program, both of which terminate in September 2009. Each of seven
    centers will focus on proteomic technology development and molecular
    mechanistic and functional studies related to a specific clinical need,
    problem, or disease. The ultimate goal of this work is to bring greater
    precision, reliability, and sensitivity to detection, diagnosis,
    treatment, and prevention strategies for the individual patient.
        We are delighted to have the opportunity to pursue these exciting
    new research avenues. I would be pleased to answer any questions the
    subcommittee may have.
                                     ______

                     Prepared Statement of Anthony S. Fauci
        Mr. Chairman and members of the subcommittee: I am pleased to
    present the President's fiscal year 2010 budget request for the
    National Institute of Allergy and Infectious Diseases (NIAID), of the
    National Institutes of Health (NIH). The fiscal year 2010 budget
    includes $4,760,295,000, which is $57,723,000 more than the fiscal year
    2009 appropriation of $4,702,572,000.
        NIAID conducts and supports biomedical research to understand,
    treat, and prevent infectious and immune-mediated diseases of domestic
    and global concern, including HIV/AIDS, tuberculosis, malaria,
    neglected tropical diseases, emerging and re-emerging infectious
    diseases. NIAID's budget request and its research projects are
    consistent with the President's multi-year commitment for cancer and
    autism. As economies and societies around the world have become
    increasingly interdependent, responding to emerging infectious
    diseases, such as the 2009-H1N1 influenza virus, as well as to long-
    established health challenges such as neglected tropical diseases, has
    taken on new urgency. As we address infectious diseases in a global
    context, we have the added benefit of contributing to preparedness
    against the threat of bioterrorism and naturally occurring disease
    outbreaks. Meanwhile, our ongoing research on domestic health
    challenges such as HIV/AIDS, influenza, and asthma, allergies, and
    other immune-mediated diseases continues to yield important advances.
    Using a multidisciplinary approach that engages academic, industry,
    governmental, and nongovernmental partners, NIAID remains committed
    both to basic immunology and infectious disease research and the
    application of this knowledge to the development of strategies to
    detect, prevent, and treat these diseases.
        The research activities of NIAID will become more important than
    ever, as current and as-yet unrecognized health threats, particularly
    in the context of the inevitability of emerging and re-emerging
    infectious diseases, will require new diagnostic, preventive, and
    therapeutic interventions. These new tools promise to have a great
    impact on the public health over the next two decades.
        We have long known that the threats posed by infectious microbes do
    not remain static, but change over time as new microbes emerge and
    familiar ones re-emerge with new properties or in new settings. This
    will not change in the coming decades. Addressing these global threats
    requires that we consider infectious diseases not through the lens of
    individual diseases, infections, or microbes in a vacuum, but by
    understanding how diseases interact in people with multiple health
    issues. Only then can we develop the tools for a comprehensive and
    practical approach to global health.
        Tuberculosis (TB) is a prototypic example of a re-emerging threat
    as an increase in the prevalence of drug-resistant forms of TB presents
    major challenges to the control of this disease. TB also is an example
    of a disease that often occurs with other infectious diseases such as
    HIV/AIDS--people co-infected with TB and HIV appear to have a more
    rapid and deadly disease course. Recently, NIAID-supported clinical
    trials have shown that mortality among TB patients co-infected with HIV
    is remarkably reduced when antiretroviral (ARV) therapy is provided at
    the same time as TB therapy. Additional studies are under way to
    determine optimal strategies for the prevention, treatment, and
    diagnosis of TB in the setting of HIV infection. NIAID continues to
    conduct and support research to create a foundation of knowledge for
    the discovery of new diagnostics, drugs and vaccines for TB, including
    drug-resistant TB. The Institute's support for public-private
    partnerships has been instrumental in linking research across sectors
    to build a robust pipeline of tools to combat TB.
        Malaria continues to exact a devastating toll on individuals
    worldwide, mostly among children in sub-Saharan Africa. Compounding the
    problem is the emergence of drug-resistant malaria parasites and
    insecticide-resistant mosquito vectors. In 2008, the Institute released
    the NIAID Strategic Plan for Malaria Research and the NIAID Research
    Agenda for Malaria. The Plan and Agenda outline our efforts to
    accelerate control and move toward eradication of malaria through
    biomedical research, including the development of prevention
    modalities, promising drugs and vaccine candidates. Accomplishing these
    goals will require the support and cooperation of malaria researchers
    and other organizations to build on the foundation of NIAID's basic
    research program in malaria. Over the next two decades, we hope to have
    a major impact on global TB and malaria burden through the development
    of vaccines that protect against these infectious killers.
        Seasonal influenza, which changes slightly every year, is the
    classic example of a re-emerging infectious disease. Influenza viruses
    also can undergo more drastic genetic changes that periodically enable
    them to evade pre-existing immunity and cause a pandemic, such as the
    deadly influenza pandemic in 1918 that killed more than 50 million
    people worldwide. NIAID has seen significant progress in its influenza
    research program, particularly in the area of pandemic influenza
    preparedness. This progress has prepared the Institute to respond
    rapidly to the newly identified 2009-H1N1 influenza virus, which has
    emerged as a public health threat in the United States, Mexico, and
    throughout the world. NIAID-funded researchers have responded quickly
    to this new threat, characterizing the virus and preparing for the
    development of a vaccine and other countermeasures.
        Nearly 28 years since the first cases of AIDS were documented, the
    terrible burden of HIV/AIDS continues to grow. The 2.7 million new
    infections worldwide in 2007 underscore the continuing urgency of the
    global AIDS pandemic, and sobering HIV/AIDS statistics in the District
    of Columbia remind us that the AIDS epidemic here in the United States
    demands our strongest efforts. Over the past two decades, NIH and
    NIAID--supported by Congress and by this subcommittee--have devoted
    substantial resources to the fight against HIV/AIDS.
        Worldwide, for every two people who receive ARV treatment, five
    others are newly infected. Therefore, our first priority in the fight
    against HIV/AIDS is prevention. NIAID-supported investigators have made
    great strides in advancing our understanding of the modalities of
    effective prevention, including those that prevent mother-to-child
    transmission of HIV. NIAID-supported research recently determined that
    medically supervised circumcision of adult males markedly reduces the
    risk of HIV acquisition through heterosexual intercourse for at least
    3.5 years after the procedure, demonstrating long-term efficacy of male
    circumcision as a prevention tool. Research conducted by our
    Microbicide Trials Network found the microbicide gel PRO 2000 to be
    safe and showed the first suggestion of potential efficacy among
    several clinical trials with other products. Of course, the most
    powerful prevention tool would be a safe and effective HIV vaccine. In
    response to the significant challenges that United States and
    international vaccine investigators have experienced in HIV vaccine
    development, NIAID has expanded our basic vaccine discovery research
    portfolio to provide the knowledge necessary to identify a viable HIV
    vaccine candidate. Our hope is that these advances in HIV prevention
    research will become part of a comprehensive HIV prevention ``toolkit''
    that will markedly decrease new infections over the next two decades.
        In addition to these prevention modalities, NIAID is boldly
    advancing three new approaches to HIV prevention. Together with
    Government and nongovernmental partners, the Institute is investigating
    the feasibility of pre-exposure prophylaxis (PrEP) for HIV prevention,
    which involves providing ARVs to HIV-negative individuals who are at
    high risk of HIV infection. Second, recent modeling data have shown
    that aggressive HIV testing and treatment potentially could reduce the
    number of new HIV cases by 95 percent in the next decade; NIAID is
    evaluating critical research questions that underpin the validity of
    this voluntary ``test and treat'' approach. Finally, NIAID is expanding
    its efforts to find a cure for HIV/AIDS. Through research to improve
    our basic understanding of HIV viral latency, we hope to achieve long-
    term HIV remission following discontinuation of effective therapy--a
    ``functional'' cure--or, ultimately, a complete eradication of residual
    virus.
        Since the acceleration of our biodefense research program in fiscal
    year 2003, NIAID has achieved major successes in the development of
    countermeasures against significant bioterrorism threats. Some
    countermeasures have been fully developed and are stockpiled or
    available for use in an emergency; others in the pipeline have been
    transferred to the HHS Biomedical Advanced Research and Development
    Authority for advanced development. Promising candidate countermeasures
    in development include ST-246, a smallpox drug candidate that has
    protected animals from an otherwise lethal exposure to live poxviruses.
        Equally important, NIAID has developed a physical and intellectual
    research infrastructure that has been critical to our ability to
    respond to new and re-emerging infectious diseases. This year, the
    Institute recompeted the Regional Centers of Excellence for Biodefense
    and Emerging Infectious Diseases, which comprise a network of 11
    regionally based, multi-institutional centers engaged in
    interdisciplinary research to develop vaccines, therapeutics, adjuvants
    and diagnostics for biodefense and emerging infectious diseases.
        Autoimmune diseases, allergic diseases, asthma, rejection of
    transplanted organs, and other immune-mediated disorders are
    significant causes of chronic disease and disability in the United
    States and throughout the world. NIAID-supported research in immunology
    and immune-mediated diseases has led to significant advances in our
    understanding of the mechanisms underlying these diseases and in the
    development of strategies to detect, prevent, and treat them.
        For example, food allergies affect the health and quality of life
    of many Americans, particularly young children. NIAID remains committed
    to basic research and clinical studies to advance the understanding of
    food allergy and food allergy-associated anaphylaxis. In June 2008,
    NIAID awarded 12, 2-year grants, totaling $2.5 million, to
    investigators to lead high-impact, innovative studies of food allergy
    under the Exploratory Investigations in Food Allergy initiative.
    Cosponsored with the Food Allergy and Anaphylaxis Network, the Food
    Allergy Project, and the U.S. Environmental Protection Agency, this
    program supports innovative pilot studies on the mechanisms of food
    allergy, with a goal of attracting new investigators to the field of
    food allergy research. We plan to renew this program in fiscal year
    2010.
        NIAID also continues to support clinical trials to prevent the
    development of food allergies and to reverse established allergy to
    milk, eggs, and peanuts. Lastly, NIAID, in collaboration with
    professional societies, advocacy groups, and other Federal agencies, is
    developing clinical guidelines to provide guidance to medical
    practitioners on the diagnosis, management, and treatment of food
    allergies.
        For more than six decades, NIAID has conducted and supported basic
    research on infectious and immune-mediated diseases that has
    underpinned the development of vaccines, therapeutics, and diagnostics.
    These, in turn, have improved health and saved millions of lives in the
    United States and around the world. Through partnerships with academic,
    industry, governmental, and nongovernmental partners, the Institute
    will continue to leverage these fundamental discoveries into the tools
    needed to achieve a healthy world.
                                     ______

          Prepared Statement of Dr. Roger I. Glass, Director, Fogarty
                              International Center
        Mr. Chairman and members of the subcommittee: I am pleased to
    present the President's budget for the Fogarty International Center
    (FIC) of the National Institutes of Health (NIH). The fiscal year 2010
    budget of $69,227,000 includes an increase of $536,000 more than the
    fiscal year 2009 appropriated level of $68,691,000.
        Over the past year, Congress has renewed its commitment to
    confronting global health issues, recognizing that these investments
    will not only improve the health and well-being of all, but also
    enhance U.S. stature abroad, economic development, and U.S.
    competitiveness. As the recent H1N1 virus outbreak illustrates, solving
    health problems in an interconnected world requires greater
    international collaboration than ever before. To effectively confront
    complex health issues that transcend national boundaries, scientific
    collaborations must be continually developed and nurtured. Research
    advances are more likely to occur when investigators study diseases on-
    site, and U.S. scientists partner with international scientists to
    develop health interventions that are responsive to local and
    international needs and priorities. This model requires a critical mass
    of trained, in-country scientists and capable institutions that are
    uniquely positioned to address local study populations and to support
    sustainable collaborations with U.S. and other investigators.
        Since its inception, the Fogarty International Center (FIC) has
    been the focal point for global health at the NIH. FIC supports and
    facilitates global health research conducted by U.S. and foreign
    investigators, builds collaborations between U.S. and health research
    institutions worldwide, and trains the next generation of scientists to
    address global health needs. FIC-supported research and research
    training programs address a wide range of diseases and needs, including
    HIV/AIDS, malaria, Tuberculosis and other infectious diseases;
    noncommunicable diseases, such as brain disorders and cancer; and
    cross-cutting areas that foster sustainable research environments,
    including research ethics and informatics for health research. In 2008,
    FIC launched a strategic plan that addresses emerging areas of science
    and shifting disease burdens, and strengthens the global health
    research workforce in the United States and around the world.
            addressing the rising burden of noncommunicable disease
        Rapidly developing countries like India, Brazil, Mexico, China, and
    Bangladesh have seen life expectancies grow for the past 40 years.
    Population forecasts now predict that by 2030, 1 out of 8 people will
    be 65 or more than 1 billion adults. In addition, poorly balanced
    nutrition, less physical activity, and tobacco use are all on the rise
    in developing countries as a result of poverty, industrialization,
    urbanization and global marketing of goods and products. With
    increasing longevity, convergence of risk factors and diseases blurs
    the distinction between disease burdens in developing and developed
    countries, and calls for a common health research agenda. International
    research collaborations to study these diseases in highly endemic areas
    accelerate scientific advances on how to prevent and treat them. In
    response to this trend, FIC established the new Millennium Promise
    Awards in Non-Communicable Disease Program in partnership with several
    other NIH Institutes, designed to support research training in low- and
    middle-income countries in fields related to cancer, stroke, lung
    diseases, obesity, and environmental factors.
        According to the World Health Organization, tobacco use kills 5.4
    million people every year--an average of 1 person every 6 seconds.
    Almost half the world's children breathe air polluted by 8 causes of
    death in the world. If current smoking patterns continue, this number
    will rise to 8 million in 2030, with approximately 80 percent of the
    deaths occurring in developing countries. FIC, in partnership with the
    National Cancer Institute and the National Institute on Drug Abuse, is
    helping to address this rising epidemic through its International
    Tobacco and Health Research and Capacity Building Program. This program
    enhances the ability of scientists in low- and middle-income nations to
    understand risk factors for smoking uptake, particularly in youth, to
    develop effective prevention and mitigation programs, and to identify
    the most effective implementation and communications strategies to
    reduce the negative impacts of smoking on populations. The knowledge
    gained and effective interventions developed abroad through the Tobacco
    Program will also benefit U.S. populations who share common risk
    factors with low-resource communities in developing countries.
        The continuing burden of infectious disease in low-income
    populations, as well as the rapid rate at which microbial agents can
    evolve, adapt and develop resistance to antibiotics, demand that FIC
    continue to invest in infectious disease research and training. In
    particular, FIC will continue to support interdisciplinary research
    that develops predictive models and principles governing the
    transmission dynamics of infectious disease agents. This will result in
    increased capacity to forecast outbreaks and improved understanding of
    how diseases like the H1N1 flu emerge and re-emerge, and strategies to
    control them.
                        advancing implementation science
        Unprecedented resources are being invested in interventions that
    have been proven safe and effective, although many have not been
    implemented on a wide scale due to logistical, cultural, financial, and
    other barriers. Bridging the gap between effective interventions and
    improved health outcomes will in large part depend on a cadre of local
    scientists who can ask and answer questions regarding what works, what
    does not, and why, in particular settings. To advance this area of
    science FIC supports research training for scientists who can generate
    knowledge to improve scale-up of interventions and help identify the
    most effective ways to translate research findings into clinical and
    public health practice.
        For example, FIC's International Clinical, Operational, and Health
    Services AIDS/TB Research Training Program is developing a network of
    researchers who are studying how to best apply research knowledge and
    new technologies related to HIV/AIDS and TB in clinical and community
    settings. With support from this program, scientists in Haiti have
    developed a new masters degree in public health program at a Haitian
    university and are training the personnel needed to monitor and
    evaluate the implementation of a new country-wide program to provide a
    standardized package of HIV care and prevention to 300,000 people per
    year.
             maintaining u.s. leadership in global health research
        If we are to continue to lead in biomedical research, then U.S.
    researchers must be supported to effectively participate in
    international science. Biomedical research has always been an
    inherently international enterprise. Many significant scientific
    advances have resulted from research conducted by teams of scientists
    working across international borders. For example, U.S. and local
    scientists together pioneered the development of oral rehydration
    therapy (ORT) for treatment of cholera. ORT is now the first line
    treatment for childhood dehydration worldwide and recommended for
    treatment of every American child with diarrhea. In this era of
    globalization, this trend will not only continue, but will likely
    become stronger. It will also require a well-trained cadre of U.S.
    health scientists who are able to work seamlessly in diverse settings.
        To this end, FIC support strengthens the ability of U.S. academic
    institutions to engage in the global scientific marketplace. The vast
    majority of FIC awards support scientists in U.S. institutions, who in
    turn collaborate with colleagues in foreign institutions. Additionally,
    FIC is capitalizing on the burgeoning interest in global health on U.S.
    university campuses through two innovative programs. First, we are
    providing a launching pad for American health sciences students and
    junior researchers to build relationships abroad and to address
    critical global health research questions through the Fogarty
    International Clinical Research Scholars Program (FICRS). This program
    responds to the acute need for future clinical investigators who can
    help translate basic research advances into clinical practice on a
    global scale. This next generation of clinical researchers will require
    hands-on experience in conducting clinical trials and clinical research
    in countries where the disease burdens are highest. The FICRS provides
    highly motivated U.S. graduate students in the health sciences and
    medical residents or fellows 1 year of mentored clinical research
    training at distinguished low- and middle-income country research
    institutions. Each U.S. student is paired with a foreign student, who
    also receives training as an equal partner, thus strengthening
    scientific capacity in the United States and abroad simultaneously.
    Several NIH Institutes partner with FIC in the effort, and therefore,
    the program includes a wide breadth of research areas, including
    cancer, maternal and child health, and extensively drug-resistant TB.
        An increasing number of U.S. and foreign academic research
    institutions are welcoming the opportunity to use their substantial
    creative resources to make a significant and lasting difference in
    global health. As scientific problems become more complex, there is a
    need for team and systems approaches to tackle important health
    challenges. To help catalyze this approach in academic research
    institutions, Fogarty's Framework Programs for Global Health support
    the development of multidisciplinary global health programs on campuses
    in the United States and in low- and middle-income countries. This
    innovative program develops new curricula and degree programs that cut
    across departments and schools to create a pipeline for a new
    generation of researchers schooled in multiple fields to address global
    health challenges. Schools representing more than 17 different
    disciplines participate in the program including, engineering,
    environmental sciences, journalism, business, law, medicine and public
    health.
        Congressman Fogarty was prescient in arguing that the needs and
    rewards of global health research will benefit the United States as
    well as the global community. FIC is extending his vision, given that
    international trade, travel and communications have created a truly
    interdependent world. As we look to the next two decades, we envision a
    world in which a global scientific workforce is equipped with the
    knowledge and the skills to better prevent and treat disease as a
    result of rigorous global research. This workforce will form the
    backbone of research institutions in the United States and abroad,
    which will be effectively linked with each other through years of
    sustained productive research and training collaborations. Working
    towards this vision moves us closer to the ideal of global health--one
    that reflects the aspiration of all people to live long and healthy
    lives.
                                     ______

       Prepared Statement of Dr. Josephine P. Briggs, Director, National
               Center for Complementary and Alternative Medicine
        Mr. Chairman and members of the subcommittee: I am pleased to
    present the President's fiscal year 2010 budget request for the
    National Center for Complementary and Alternative Medicine (NCCAM) of
    the National Institutes of Health (NIH). The fiscal year 2010 budget
    includes $127,241,000, which is $1,770,000 more than the comparable
    fiscal year 2009 appropriation of $125,471,000.
        In December 2008, the NCCAM, in conjunction with the National
    Center for Health Statistics, released data from the 2007 National
    Health Interview Survey (NHIS).\1\ The survey is the most comprehensive
    and reliable information to date on the use of complementary and
    alternative medicine (CAM) in the United States. The 2007 NHIS data
    confirm that millions of Americans--38 percent of U.S. adults and 1 in
    9 children--use CAM to promote health and wellness and to address
    specific conditions such as chronic pain.
    ---------------------------------------------------------------------------
        \1\ Barnes PM, Bloom B, Nahin R. CDC National Health Statistics
    Report#12. Complementary and Alternative Medicine Use Among Adults and
    Children: United States, 2007. December 10, 2008.
    ---------------------------------------------------------------------------
        The NHIS data affirm the public health importance of NCCAM's
    mission to develop an evidence base for the integration of CAM with
    conventional healthcare and to disseminate research results to the
    public and healthcare professionals. Since its founding 10 years ago,
    NCCAM has created a nationwide CAM research enterprise, built on sound
    scientific principles, that enables the rigorous study of CAM. Among
    NCCAM's accomplishments are a Centers of Excellence program at leading
    biomedical research institutions; standards for quality and stability
    for the natural products used in research; and the development of tools
    and methodologies to discover the potential benefits and risks of CAM
    modalities. Today, under NCCAM's leadership, partnerships between
    biomedical research institutions and CAM institutions and practitioners
    are engaged in state-of-the-art scientific research. NCCAM-supported
    CAM research has resulted in more than 3,300 peer-reviewed
    publications. Professional associations, such as the American College
    of Physicians and the American Academy of Orthopedic Surgeons are now
    able to use CAM research findings to inform their practice guidelines.
    NCCAM will continue to meet the challenges of building the evidence
    base for CAM interventions through its rigorous research, research
    training, and outreach endeavors. NCCAM's budget request and its
    research projects are consistent with the President's multi-year
    commitment for cancer and autism.
                a structured approach to answering key questions
        CAM research is a promising scientific endeavor that requires
    multidisciplinary basic, translational, and clinical trial
    collaborations. In fiscal year 2010, NCCAM will fund awards under a new
    initiative, Partnerships for Complementary and Alternative Medicine
    Clinical Translational Research. This initiative, which replaces the
    NCCAM Developmental Centers for Research on CAM program, will foster
    such collaborations at CAM institutions and create tools and
    methodologies for research.
        NCCAM investigations span the continuum of research areas: basic
    (How does the therapy affect the body?); translational (Do we have the
    methods and tools to detect and measure the modality's effects?);
    efficacy (Is there evidence of safety and benefit under optimal
    research conditions?); and effectiveness (How well does the CAM
    practice work in the ``real world'' and in comparison to other
    treatments?). NCCAM has strong programs in all four of these areas; its
    current research strategy places particular emphasis on strengthening
    effectiveness research.
             area of promise and investment: managing chronic pain
        The 2007 NHIS data indicate that chronic pain is, by far, the most
    common health problem for which Americans turn to CAM. NCCAM-supported
    basic, translational, and clinical research is using state-of-the-art
    neuroscience, brain imaging, and novel study designs to demonstrate
    that mind-body medicine approaches, such as massage, chiropractic, and
    acupuncture, affect pain perception and to understand how patient
    expectancy and practitioner reassurance may have an impact on pain
    management. For example, using functional magnetic resonance imaging
    (fMRI) and positron emission tomography (PET), basic researchers are
    developing important insights into how acupuncture affects specific
    pain networks in the brain. In addition, emerging data, such as the
    recent report in the Annals of Internal Medicine that massage therapy
    and simple touch may provide pain relief for advanced cancer patients,
    point to the promise of mind-body practices. NCCAM is focusing on
    developing the evidence base for the use of nonpharmacologic CAM
    practices for pain management.
        Chronic back pain is a problem for millions of Americans, and costs
    associated with it total at least $50 billion annually. \2\ It is often
    difficult to treat, and medications used to address it can have
    troubling side effects. Certain CAM therapies, such as acupuncture,
    chiropractic, massage, and yoga, show promise in treating chronic back
    pain. In May 2009, NCCAM is sponsoring, with other NIH Institutes and
    Centers, a workshop on nonpharmacologic interventions for the treatment
    of chronic back pain, bringing together experts to identify gaps in the
    CAM evidence base and opportunities for future research. NCCAM plans to
    fund awards in fiscal year 2010 under a new initiative, Effectiveness
    Research--CAM Interventions and Chronic Back Pain. This initiative will
    support studies of CAM approaches to address a range of outcomes for
    back pain, such as reduced dependency on narcotics.
    ---------------------------------------------------------------------------
        \2\ Low Back Pain Fact Sheet; National Institute of Neurological
    Disorders and Stroke, National Institutes of Health, Department of
    Health and Human Services, July 2003.
    ---------------------------------------------------------------------------
              area of promise and investment: translational tools
        Basic and translational (i.e., ``bench-to-bedside'') research is
    especially challenging for CAM mind-body practices, acupuncture, and
    body-based and manipulative therapies, because current scientific
    methods may not adequately capture and measure the effects of these
    therapies. To decipher these practices' potential physiological effects
    and enable scientists to study them in clinical trials, better
    scientific tools, metrics, and methodologies must be developed. In
    fiscal year 2010, NCCAM will fund awards under its initiative, Program
    for Translational Tools for CAM Clinical Research. The research
    supported under this initiative will improve the quality and
    reproducibility of CAM clinical investigations.
                area of promise and investment: natural products
        According to the 2007 NHIS, almost 40 million U.S. adults and 2.850
    million children use natural products to manage their health and
    wellness. Given the widespread use of dietary supplements, NCCAM's
    research into the safety and efficacy of natural products remains a
    public health priority.
        NCCAM-supported studies, including collaborations under the NIH
    Botanical Research Centers program, demonstrate the promise of natural
    products research. For natural products, basic and translational
    research remains critical precursors to large-scale clinical trials. A
    recent study by the University of Maryland and Rutgers University
    elucidated an immune system mechanism of action of green tea
    polyphenols on rheumatoid arthritis. In another study, Duke University
    researchers reported that bromelain, an enzyme derived from pineapple
    stems, reduced inflammation resulting from Crohn's disease and
    ulcerative colitis.
        Although natural products research shows great promise, product
    quality remains a significant issue. In July 2008, an NCCAM-funded
    study in the Journal of the American Medical Association reported that
    one-fifth of Internet-available Ayurvedic medicines contained
    detectable levels of lead, mercury, and arsenic. The authors also found
    evidence for benefit of industry-established standards for quality in
    reducing levels of toxic metals. NCCAM has led the scientific community
    in requiring that all natural products used in its research undergo
    quality and stability screening to ensure that the research is safe and
    reproducible. Ongoing collaborations with the dietary supplement
    industry are important to this effort. Equally important are NIH
    partnerships in the development of an evidence base for natural
    products.
                        making wise decisions: outreach
        Studies confirm that consumers do not tell their doctors that they
    use CAM, and doctors do not ask their patients about CAM use. To ensure
    safe, coordinated care NCCAM developed its time to talk patient and
    provider education program. NCCAM also partnered with the National
    Institute on Aging to develop a CAM section on NIH Senior Health, the
    NIH Web site especially for older adults.
        In fiscal year 2009, NCCAM will initiate a new educational section
    of its Web site (nccam.nih.gov) to provide health professionals with
    evidence-based information and clinical practice guidelines on CAM use.
    NCCAM also cosponsored the North American Research Conference on
    Complementary and Integrative Medicine, on May 12-15, 2009. This
    international meeting of scientists and CAM and conventional
    practitioners highlighted the emerging science on CAM and future
    directions for research.
                          nccam: looking to the future
        There are areas of considerable promise and potential for the field
    of CAM research, and NCCAM will focus its resources to ensure that they
    will be optimally directed. The Center has begun to develop its next
    strategic plan, seeking the input of the scientific community as well
    as its diverse community of stakeholders. As a first step in this
    process, the Center has convened a Blue Ribbon Panel to consider future
    directions for its intramural research program.
        Thank you for the opportunity to testify. I would be pleased to
    answer the subcommittee's questions.
                                     ______

    Prepared Statement of Dr. Barbara M. Alving, Director, National Center
                             for Research Resources
        Mr. Chairman and members of the subcommittee: It is a privilege to
    present to you the President's budget request for the National Center
    for Research Resources (NCRR) for fiscal year 2010. The fiscal year
    2010 budget of $1,252,044,000 includes an increase of $25,781,000 more
    than the fiscal year 2009 appropriated level of $1,226,263,000. NCRR's
    funding priorities for fiscal year 2010 include expansion of the
    Clinical and Translational Science Awards (CTSA) program. Additionally,
    NCRR will sustain the range of activities supported by the Center's
    other major programs, including the Research Centers in Minority
    Institutions, the Institutional Development Awards, the National
    Primate Research Centers, and the Biomedical Technology Research
    Centers.
        The mission of the NCRR, as one of the 27 Institutes and Centers of
    the National Institutes of Health (NIH), is to provide support and
    training for researchers that extend from the laboratory to clinical
    trials and into dissemination of prevention strategies and treatments
    that will impact communities as well as patients.
             appreciation for investment in research infrastructure
        On behalf of NCRR and the research community, I extend our
    appreciation to the President and the Congress for the $1.6 billion
    allocated to our Center as American Recovery and Reinvestment Act
    (ARRA) funding. We will ensure that the $1 billion for extramural
    construction funding and the $300 million in shared instrumentation
    funds are invested wisely at academic institutions throughout the
    Nation. The NCRR is using the additional ARRA funding to supplement
    awards in the Institutional Development Award (IDeA) program, the
    Research Centers in Minority Institutions (RCMI) program, the Clinical
    and Translational Science Award (CTSA) program, as well as other NCRR
    programs.
           building a matrix for clinical and translational research
        The NCRR, through its stewardship of the IDeA, RCMI, and CTSA
    programs, is linking investigators and communities by supporting and
    encouraging collaborations for training, sharing of data, accelerating
    advances in research and clinical informatics, and dissemination of
    best practices for community engagement. For example, the University of
    Washington CTSA is partnering with academic institutions in IDeA States
    to create greater opportunities to reach underserved populations. CTSAs
    are also connecting with RCMIs: Emory University (Atlanta) is
    partnering with Morehouse School of Medicine; Vanderbilt University
    (Nashville, Tennessee is partnering with Meharry Medical College; and
    Weill Cornell Medical College (New York) is partnering with Hunter
    College.
        Led by NCRR, the CTSA program is a partnership between the NIH and
    a national consortium of 39 academic health centers and research
    institutions to build academic homes for clinical and translational
    research. The CTSA program is designed to translate more efficiently
    the rapidly evolving knowledge developed in basic biomedical research
    into treatments to improve human health. Additionally, the CTSAs are
    training a new generation of clinical and translational researchers to
    excel in the interdisciplinary, team science environment.
        The momentum of the national CTSA consortium continues to build as
    new connections are rapidly emerging within, across, and beyond the
    consortium. In the last year, 15 new CTSAs joined the consortium,
    adding representation from 5 new States, additional pediatric
    expertise, and greater informatics capabilities. When the program is
    fully implemented, the NCRR expects to fund CTSA awards at 60
    institutions at a total cost of $500 million per year. As the CTSA
    program increases in complexity and size, institutions are forming
    regional consortia to focus on shared goals with greater efficiency.
        The CTSA institutions are using business principles and practices
    to improve the processes involved in translational research.
    Investigators and core facilities directors at the CTSA at Yale
    University are increasing efficiencies and reducing redundancies by
    using Web-based resources and systems to maximize the use of their core
    research facilities, which include imaging, informatics, and genomic.
    Thanks to this integration, researchers now have improved access to
    sophisticated technologies and valuable expertise with less
    administrative burden.
        The CTSA consortium has identified five strategic goals: (1) to
    develop strategies and resources to move laboratory discoveries into
    early clinical testing (T1 translation); (2) to reduce complexities and
    improve ways clinical and translational research is conducted; (3) to
    enhance training and career development of clinical and translational
    investigators; (4) to encourage consortium-wide collaborations; and (5)
    to improve the health of communities across the Nation.
                      fostering t1 translational research
        The potential to accelerate research discoveries from the bench
    into early clinical studies (T1) usually requires preclinical studies,
    those studies that involve the appropriate animal models. Currently,
    researchers with expertise in animal models (including mouse, rat, and
    nonhuman primate models) are working with CTSA investigators on pilot
    projects that focus on cardiovascular disease, ovarian cancer, and
    other diseases. NCRR and its National Primate Research Centers are
    working closely with National Institute of Allergies and Infectious
    Diseases and the NIH Office of AIDS Research to ensure that adequate
    numbers of animals and resources are available to meet the need for
    development of new AIDS vaccines.
        NCRR's Biomedical Technology Research Centers are cutting-edge
    interdisciplinary centers that create transformative technological and
    computational infrastructure for biomedical research. The CTSAs are
    leveraging the expertise of investigators in these centers to conduct a
    wide range of translational research, from cell biology to clinical
    imaging.
             leveraging partnerships to benefit biomedical science
        The CTSAs are realizing returns on their research discoveries by
    securing patents and licensing them. From 2006 to 2008, the CTSAs
    established more than 350 academic, public, and private partnerships.
    To achieve its overall mission to speed the translation of scientific
    discoveries to improve human health, the CTSAs are establishing
    innovative partnerships with industry to accelerate the development of
    treatments, diagnostics, and devices. For example, the CTSA at Scripps
    Research Institute is collaborating with Qualcomm to develop and
    clinically validate biosensors--tiny devices that measure body
    functions--and other wireless healthcare technologies. Similarly, the
    Oregon Health and Science University is partnering with Intel to apply
    wireless and mobile technology with various sensors to enable earlier
    detection and treatment of life-threatening events for diabetics and
    individuals at high risk of stroke.
        Ensuring that the public is actively engaged in research and
    benefiting from research findings is a key component of the CTSA
    program. One example of ways CTSAs are improving the health of their
    communities is a collaborative effort in Houston, which is helping
    children in two inner-city neighborhoods make healthier lifestyle
    choices and reduce their risk of obesity. CTSAs in Chicago have joined
    forces to ensure active participation from their communities throughout
    all stages of research--from project design to results dissemination.
    Similarly, connections between the CTSA consortium and NCRR's Science
    Education Partnership Award program are growing, helping to inspire the
    next generation of researchers. As an example, the University of
    Pittsburgh CTSA and Science Education Partnership Award investigators
    hosted an outreach event for middle school students, featuring a mobile
    science laboratory.
                         improving research informatics
        NCRR continues to support informatics tools and resources to
    enhance research collaboration. For example, NCRR is funding a
    Biomedical Informatics Research Network coordinating center at the
    University of Southern California to enhance data sharing among the
    network's research centers and other researchers. Through an ARRA-
    funded initiative, NCRR will facilitate interdisciplinary collaboration
    and scientific exchange by developing tools and infrastructure that
    will help connect basic, clinical, and translational investigators and
    students with other researchers that share their interests or who could
    benefit from their expertise. NCRR also plans to support development of
    an animal models informatics resource to provide researchers with one-
    stop access to information related to animal models of human disease.
                          expanding research capacity
        NCRR is enhancing the capabilities of RCMIs to conduct clinical and
    translational science through the RCMI Infrastructure for Clinical and
    Translational Research Awards. Funding may be used for out-patient
    clinical resources, biostatistical support, core laboratories, and
    patient-oriented research infrastructure. This award is a
    reorganization of previous RCMI programmatic activities and will
    enhance research capacity, improve collaboration between translational
    and clinical researchers, facilitate multidisciplinary training and
    career development and enable seamless interactions with CTSAs.
        The IDeA program fosters health-related research and increases the
    competitiveness of investigators in 23 States and Puerto Rico. NCRR's
    previous investments in developing research capacity through its IDeA
    program have resulted in additional funding opportunities for
    investigators. For example, the University of Kansas recently received
    $9.6 million in grants from non-Federal sources for drug development
    efforts; the expertise that provided the foundation for this award
    grew, in part, from funding for a center of excellence in the IDeA
    program.
        This snapshot of NCRR's programs and activities demonstrates our
    continuing commitment to advancing clinical and translational research.
    NCRR's budget request and its research projects are consistent with the
    President's multi-year commitment to finding cures for cancer and
    autism. By encouraging collaboration among our clinical and
    translational programs, NCRR is maximizing the Nation's investment to
    translate research discoveries into improved treatments for patients.
                                     ______

       Prepared Statement of Dr. Paul A. Sieving, Director, National Eye
                                   Institute
        Mr. Chairman and members of the subcommittee: I am pleased to
    present the President's budget request for the National Eye Institute
    (NEI). The fiscal year 2010 budget of $695,789,000 includes an increase
    of $7,309,000 more than the fiscal year 2009 appropriation level of
    $688,480,000.
                              ophthalmic genetics
        The loss of sight affects us in fundamental ways, threatening
    independence, mobility, and quality of life. Many eye diseases strike
    later in life. Thus, as life expectancy has increased, more Americans
    have become susceptible to vision loss and blindness. One such disease,
    age-related macular degeneration (AMD), is the leading cause of vision
    loss in the United States. AMD causes a progressive loss of light-
    sensing cells in the macula, the center of the retina, making it
    difficult to read, recognize faces, drive a car, or perform even simple
    tasks that require hand-eye coordination. Based on published study
    data, 8 million older Americans are at risk to develop advanced AMD.
        Advanced AMD can take two distinct forms, either geographic atrophy
    or wet AMD. In geographic atrophy, large areas of the retina atrophy
    and die. In wet AMD, abnormal blood vessels grow into the retina,
    leaking blood and serum that damages the retina. Previous studies have
    found several gene variants, which regulate inflammation, are
    associated with the ``wet'' type of AMD. These variants are thought to
    lead to chronic, overactive inflammatory responses that damage retinal
    tissue and eventually lead to AMD. Most recently, the first gene
    associated exclusively with the geographic atrophy, namely the Toll-
    like receptor 3 (TLR3) gene, was published. The TLR3 gene encodes a
    viral sensor which activates immune responses. When TLR3 activates in
    response to certain viruses, it induces cell death in the retina thus
    causing geographic atrophy. Alternatively, in humans, it appears that
    low activity of TLR3 confers protection against geographic atrophy,
    most likely by sparing the death of retinal cells. This is the first
    evidence that viral infection may contribute to the development of
    geographic atrophy. Ongoing work includes screening for viruses in
    affected individuals as well as developing methods to decrease TLR3
    activity in the retina.
        Glaucoma is a group of eye disorders that share a distinct type of
    optic nerve damage, which can lead to blindness. Elevated intraocular
    pressure is frequently, but not always, associated with glaucoma.
    Published study data find that approximately 2.2 million Americans have
    glaucoma and a similar number are unaware that they have developed the
    disease. Like AMD, glaucoma is a genetically complex disease likely
    involving many changes in many genes. NEI is committed to exploiting
    the latest genetic technologies in finding the genes that contribute to
    this common disorder. To this end, NEI initiated funding for genome-
    wide association studies, a powerful approach that enables
    investigators to scan the entire human genome to detect multiple,
    subtle gene variants that increase the risk of developing this complex,
    blinding disease. Knowledge of the genetic basis of glaucoma is crucial
    to developing personalized therapies that target specific genes in
    order to prevent vision loss.
        Each genetic discovery has made it possible to study the implicated
    gene's function in health and disease. NEI investigators have made
    considerable progress in understanding the molecular mechanisms of
    genetic eye disorders and are developing rational therapies that
    address the molecular cause of the disease. The first success in this
    translational research effort are the reports of positive results from
    recent phase I clinical trials of gene transfer in a form of Leber
    congenital amaurosis, a severe, early onset retinal disease. In the
    effort to accelerate progress NEI established eyeGENE, a research
    program that offers genetic testing to patients through a national
    network of vision research laboratories in exchange for participation
    in a secure, confidential patient registry and DNA repository. DNA
    samples and corresponding diagnostic and clinical information are made
    available to the vision research community to recruit patients for
    clinical trials and to conduct genetic and molecular studies. eyeGENE
    represents a new paradigm to personalize medical care in the practice
    of ophthalmology. Knowledge of an individual's genomic profile will
    enable patients to make informed decisions about presymptomatic,
    preventive treatments or highly targeted molecular therapeutics.
                             translational medicine
        Neovascularization refers to the growth of new blood vessels. In
    some diseases, such as diabetic retinopathy and AMD, neovascularization
    is mistakenly activated and becomes a major pathologic consequence of
    the disease. Neovascularization can cause severe and irreversible
    vision loss due to abnormal vessel growth and consequent fluid leakage
    into the retina. Previous studies have established vascular endothelial
    growth factor (VEGF) spurs neovascularization and several therapies
    have been developed to prevent the abnormal activation of the VEGF
    protein. A recent National Institutes of Health (NIH) supported study
    reports on the discovery of a protein, Roundabout4 (Robo4), that
    stabilizes the existing vasculature and prevents neovascularization by
    inhibiting VEGF activity. Robo4 maintains vascular integrity by
    inhibiting VEGF-induced cell migration, vessel formation, and
    permeability. Vascular eye diseases are the most common cause of vision
    loss in the United States. This study suggests a new and promising
    therapeutic avenue to control neovascularization by regulating Robo4
    activity.
        RNA interference is a new approach that has been touted as having
    great potential for treating many diseases. This method harnesses a
    naturally occurring process that cells employ to control gene
    expression. By designing a small, interfering RNA sequence (siRNA), it
    is thought investigators can target and silence specific genes with
    specific siRNAs. Vision researchers have developed siRNA sequences to
    prevent the expression of VEGF in AMD and diabetic retinopathy that
    have been demonstrated to prevent neovascularization in animal models.
    However, a recent NEI-supported study suggests that siRNA may not
    always target the intended gene to initiate RNA interference. This
    study provides an important cautionary note to the entire field of
    siRNA that systemic administration of this treatment may have
    unintended consequences and side effects.
                              visual neuroscience
        Although the function of astrocytes, a cell type found in the brain
    and central nervous system, is not entirely understood, they have long
    been thought to maintain normal neuronal function. More recent evidence
    suggests that astrocytes may have some function in neural signaling and
    processing. Recently, NEI investigators found key evidence that
    astrocytes also act as a critical intermediary between neurons and
    local blood flow. In this study, inhibition of astrocyte activity
    decreased local blood flow. This finding explains why imaging devices,
    like functional MRI, detect blood flow changes that correspond to
    neuronal activity. Pathologic changes in astrocytes are implicated in
    Parkinson's, Alzheimer's, and other neurodegenerative diseases. The
    specific effect of astrocyte activity on the hemodynamic response
    provides a basis for the interpretation of functional MRI, adding
    qualitatively to the clinical and research utility of this powerful
    imaging tool across the broad spectrum of neurologic disease.
                        clinical trials and diagnostics
        Cataracts (clouding of the ocular lens) remain the primary cause of
    blindness in the world today. Researchers at NEI and NASA collaborated
    to develop a dynamic light scattering device which allows clinicians to
    detect and quantify the amount of unbound alpha crystallin proteins in
    an intact eye. With this device, it is now possible to safely and
    reproducibly measure the extent of lens damage and cataract formation
    caused by oxidative stress to a patient's eye (and perhaps the body) by
    measuring alpha crystallin reserves. This provides clinicians with the
    ability to monitor lens health, and may allow preventive or therapeutic
    actions that delay or eliminate cataract formation and blindness.
        Each year approximately 33,000 Americans undergo corneal
    transplants to replace diseased corneas, the normally transparent
    tissue that protects the eye and helps focus light on the retina.
    Corneal transplants are among the most common and successful
    transplantation procedures in medicine but sufficient donor is not
    available. Eye banks, the primary source of donor tissue, refrain from
    harvesting tissue from donors over age 65 because of uncertainty about
    the integrity of older corneas. However, the recently published Cornea
    Donor Study (CDS) found that corneal transplants using tissue from
    older donors, ages 66 to 75, have similar success rates as tissue from
    younger donors, ages 12 to 65. Based on these findings, the study
    authors recommend that the age limit for donor tissue should be
    expanded to 75. The CDS study gives eye banks, transplant surgeons, and
    patients confidence in the use of older donor tissue. This finding
    should help eye banks keep pace with the demand for corneal tissue.
                             medicine of the future
        Development of an artificial cornea will provide an abundant source
    of nonimmunogenic tissue for transplantation. Cell transplantation has
    prevented vision loss in rodent models of retinal disease. It is likely
    that these efforts will culminate in viable forms of regenerative
    medicine for eye disease. Genomic medicine will allow us to predict
    susceptibility to disease and pre-empt it with a variety of gene-based
    therapies. Gene transfer will likely become an option to treat many
    retinal degenerative diseases. We will have the opportunity to restore
    ambulatory vision to the blind through new prosthetic devices that
    reproduce vision electronically. Such devices will allow those with
    untreatable conditions to maintain independence and mobility. While
    there is much work ahead, current research efforts to treat and cure
    eye disease are very promising.
                           cancer research portfolio
        NEI funds basic research on cell biology, development and the
    regulation of blood vessel growth where findings could have relevance
    to our understanding and treatment of cancer. NEI also supports a phase
    III clinical trial on the treatment of retinoblastoma, a cancerous,
    blinding and potentially fatal eye disease. Consistent with the fiscal
    year 2010 NIH priority to expand cancer research funding, NEI will
    increase its fiscal year 2010 commitment to this portion of the
    portfolio by 4.4 percent.
                                     ______

    Prepared Statement of Dr. Alan E. Guttmacher, Acting Director, National
                        Human Genome Research Institute
        Mr. Chairman and members of the subcommittee: I am pleased to
    present the President's fiscal year 2010 budget request for the
    National Human Genome Research Institute (NHGRI) of the National
    Institutes of Health (NIH). The fiscal year 2010 budget includes
    $509,594,000, which is $7,227,000 more than the fiscal year 2009
    appropriation of $502,367,000.
        NHGRI's budget request and its research projects are consistent
    with the President's multi-year commitment for cancer.
            windfall of discoveries of the genetic basis of disease
        The Nation's previous investments in the Human Genome Project and
    the International HapMap Project have moved research forward into many
    diseases with unprecedented speed. HapMap-enabled genome-wide
    association studies (GWAS) identify a stunning number--more than 130 in
    2008 alone--of genetic factors associated with major causes of
    morbidity and mortality in the United States, such as autism, diabetes,
    cardiovascular disease, lung and prostate cancer, and inflammatory
    bowel disease. Identification of gene variants associated with disease
    raises the possibility of using genetic testing, in combination with
    family history information, to identify susceptible, pre-symptomatic
    subjects for screening and preventive therapies. It also provides key
    new understanding of the gene-environment interactions and biological
    pathways that lead to disease, thus providing new insights into
    treatment and prevention.
                            the cancer genome atlas
        Initiated in fiscal year 2007, the TCGA is a pilot project, jointly
    supported and led by the NHGRI and the National Cancer Institute (NCI)
    that applies a comprehensive, large-scale genomic analysis approach to
    cancer research. TCGA is designed to develop and test the complex
    scientific and technological approaches needed to identify the
    mutations and other genomic changes associated with various types of
    cancer. Three NHGRI-supported sequencing centers provide genomic
    sequencing capability for the TCGA. In fiscal year 2008, the first
    major results of this pilot project were obtained for the most common
    form of brain cancer, glioblastoma multiforme. Another very exciting
    result was an unexpected observation that points to a potential
    mechanism of resistance to a common chemotherapy drug used for brain
    cancer. These first results from the TCGA pilot project represent an
    exciting indication of the value of the multi-dimensional analysis of
    the molecular characteristics in human cancer. In the next 1 to 2
    years, the focus of TCGA will be on two other common cancers, squamous
    cell lung cancer and ovarian cancer, as well as further analysis of
    glioblastoma (brain cancer), as well as potential scale up to deal with
    many other forms of cancer.
                               medical sequencing
        The NHGRI's medical sequencing program aims to drive continued
    technology improvement (lowering the cost of genome sequencing) and to
    produce data useful to biomedical research. Seven studies are currently
    underway to identify the genes responsible for several relatively rare,
    ``single-gene'' diseases and to survey the range of gene variants that
    contribute to certain common diseases. In fiscal year 2008, a number of
    medical sequencing projects were initiated: (1) Sequencing the genomic
    regions identified in genome-wide association studies as containing
    genetic components underlying common diseases, such as diabetes, breast
    cancer, schizophrenia, or Crohn's disease; (2) Sequencing the genomes
    of important human pathogens, such as those that cause malaria and
    sleeping sickness, and their invertebrate vectors (in collaboration
    with the National Institute of Allergy and Infectious Disease; and (3)
    the TCGA project.
                         personalized genomic medicine
        In addition to basic research underway to support medical
    applications of genomics, two clinical genomics initiatives launched in
    fiscal year 2007 are now in full stride. The first, ClinSeq, is a pilot
    study aimed at developing technological and procedural approaches to
    facilitate large-scale medical sequencing in a clinical research
    setting. The second, the Multiplex Initiative, is a study intended to
    provide genetic susceptibility testing for several common health
    conditions, such as cardiovascular disease and osteoporosis, to
    evaluate patients' reactions to the testing and receipt of results.
                            the 1000 genomes project
        The 1000 Genomes Project builds on the human haplotype map
    developed by the International HapMap Project to produce a much more
    comprehensive view of genomic variation. In fact, it aims to find
    almost all the variants in the genome, including those that contribute
    to disease risk. The 1000 Genomes Project will map not only the single-
    letter differences in people's DNA, called single nucleotide
    polymorphisms, but also will produce a high-resolution map of larger
    differences in genome structure called structural variants, which are
    rearrangements, insertions, deletions, or duplications of DNA segments.
    The importance of these structural variants has become increasingly
    clear from surveys completed in the past 18 months that demonstrate
    that differences in genome structure may play a role in susceptibility
    to such conditions as mental retardation and autism.
        The project includes large-scale implementation of several new
    sequencing platforms to capitalize on the cost reductions emerging from
    evolving technologies, described in the journal Nature Biotechnology in
    October 2008. Using standard DNA sequencing strategies, the effort
    would likely cost more than $500 million. However, the cost of the
    project is expected to be far lower to the program--$30 million to $50
    million--due to the project's pioneering implementation of new
    technologies.
                             large-scale sequencing
        Currently, 197 genomes are either in the pipeline or have been
    completed by the NHGRI-supported large-scale sequencing centers, which
    are world leaders, renowned for their cost-effective and high-quality
    work. Completed in fiscal year 2009, the most recent study of a cow was
    an important development in agriculture that may lead to higher-quality
    beef and milk production and possibly lower carbon dioxide emissions.
    Ongoing sequencing targets include several nonhuman primates, mammals,
    fungi, and multiple strains of yeast.
                               the $1,000 genome
        The NHGRI's continuing commitment to the development of innovative
    sequencing technologies, which reduces the cost and increases the speed
    of DNA sequencing, fuels the swift pace of genomic discoveries. In the
    past year, several groups have demonstrated the ability to work with
    individual DNA strands and read individual DNA bases. These two
    breakthroughs are being combined to deliver the ability to sequence DNA
    isolated directly from cells without any processing apart from
    purification. This is one technology with promise to achieve the goal
    of sequencing a genome for $1,000 by 2014, NHGRI's original goal.
                                genomic function
        The NHGRI supports research to identify and characterize the
    function of all parts of our genome and to understand their biological
    relevance. Efforts to uncover functional elements are not limited to
    the human genome, since understanding the genomes of other, ``model,''
    organisms also can give insight into the structure and function of the
    human genome.
        Following a successful pilot project, the NHGRI implemented a full-
    scale ENCyclopedia of DNA Elements (ENCODE) Project in fiscal year 2007
    to examine the entire human genome for sequence-based functional
    elements. Concurrently, the NHGRI initiated modENCODE, which has
    similar goals for the analysis of the genomes of two important model
    organisms. This program will take advantage of the small, more
    manageable genomes of these organisms to unlock the function of the
    many genes they share with humans.
                    ethical, legal, and social implications
        The NHGRI supports six Centers of Excellence in Ethical, Legal, and
    Social Implications (ELSI) Research. The Centers focus on issues
    surrounding large-scale genomics research and emerging genetic
    technologies. The NHGRI continues to support ELSI research as a core
    aspect of our research portfolio in an effort to anticipate and address
    the societal issues that will continue to arise as we learn ever more
    about the human genome and its contributions to human health and
    disease.
                                 moving forward
        The NHGRI recently began two new programs to harness genomic
    knowledge and technology to help patients whose needs are not met by
    existing scientific and medical programs. Launched in 2008, the
    Undiagnosed Diseases Program (UDP), jointly led by the NHGRI, the NIH
    Clinical Center, and the Office of Rare Diseases Research, focuses on
    the most puzzling medical cases referred to the NIH by physicians
    across the Nation. The NIH Therapeutics for Rare and Neglected Diseases
    (TRND) Program, launched in fiscal year 2009, builds upon the
    technology and strategies of high-throughput genomics to identify and
    shepherd novel therapeutics for diseases where the risks of failure are
    currently too high for the private sector, but the human need is too
    great to ignore. These conditions by definition either occur in fewer
    than 200,000 Americans or in the developing world, limiting the profit
    motive for industry. UDP and TRND exemplify how the country can
    leverage the advances funded and developed by the NHGRI and the NIH to
    drive the development of more personalized, predictive, pre-emptive,
    and participatory diagnostic and therapeutic options, improving health
    outcomes for all Americans.
                                     ______

        Prepared Statement of Dr. Richard J. Hodes, Director, National
                               Institute on Aging
        Mr. Chairman and members of the subcommittee: I am pleased to
    present the President's fiscal year 2010 budget request for the
    National Institute on Aging (NIA) of the National Institutes of Health
    (NIH). The fiscal year 2010 budget includes $1,093,143,000, which is
    $12,347,000 more than the fiscal year 2009 appropriation of
    $1,080,796,000.
        Our Nation is currently in the midst of an unprecedented
    demographic shift. The number of Americans ages 65 and older is
    expected to double within 25 years. In less than 50 years, the number
    of ``oldest old''--people ages 85 and older--will more than quadruple.
    As record numbers of Americans reach retirement age and beyond,
    profound changes will occur in our economic, healthcare, and social
    systems.
        The NIA leads a national effort to understand the nature of aging
    and the diseases and conditions that are more common among older adults
    and to develop interventions that will help older adults enjoy robust
    health and independence, remain physically active, and continue to make
    positive contributions to their families and communities. We support
    and conduct a comprehensive and integrated portfolio of genetic,
    biological, clinical, behavioral, and social research related to the
    aging process, healthy aging, and diseases and conditions that often
    increase with age.
             understanding healthy aging and disease and disability
        Modern medicine and new insights into lifestyle and other
    environmental influences are allowing a growing number of people to
    remain healthy and socially and emotionally vital into advanced ages,
    and NIA remains at the forefront of the Nation's efforts to identify
    the genetic, physical, emotional, and environmental factors that
    contribute to healthy old age. For example, researchers on the NIA-
    supported Long Life Family Study are analyzing data from families with
    two or more siblings over age 79 to identify factors that may
    contribute to long and healthy life, and the Longevity Consortium
    brings together leading researchers to facilitate the discovery,
    confirmation, and understanding of genetic determinants of longevity.
    NIA intramural investigators are continuing the SardiNIA Project to
    search for genes associated with nearly 100 traits in a small,
    genetically homogeneous population and the Age, Gene/Environment
    Susceptibility (AGES) Study to explore genetic susceptibility and gene/
    environment interactions that contribute to various health outcomes in
    old age.
        NIA's biology programs are wide ranging and address organs,
    systems, and processes throughout the body. For example, the Institute
    supports research on long-term weight maintenance, diet composition,
    and energy balance as well as the role of nutrition in the prevention
    of common age-related conditions such as heart disease and cancer. NIA
    is also collaborating with the National Institute of Allergy and
    Infectious Diseases to support research to better understand the
    mechanisms underlying age-related decline of the thymus, an organ that
    produces white blood cells known as T cells, a critical component of
    the body's ability to launch a robust immune response against
    infections. Studies on basic bone biology have led to the surprising
    finding that the protein Lrp5, an important factor in the process
    through which new bone is created, regulates bone mass formation
    through serotonin synthesis in the intestine, and not by acting
    directly on the bone, as was previously believed. This finding broadens
    our understanding of bone remodeling and suggests new therapeutic
    approaches to increase bone mass. Research initiatives to help us
    better understand mechanisms of anemia, chronic kidney disease, and
    thyroid dysfunction in the elderly have also been established at NIA,
    and an advisory ``summit'' meeting was held in September 2008 to
    identify areas of scientific opportunity and facilitate the formulation
    of future plans for research on the underlying biology of aging-related
    changes.
        Cognitive aging is a high-priority research area for NIA. A new
    focus on brain health, as opposed to the study of specific causes of
    brain disease and dysfunction, has emerged in recent years and has
    become an increasingly important paradigm in neuroscience research. NIA
    is continuing its involvement with the trans-NIH Cognitive and
    Emotional Health Project to coordinate and accelerate research leading
    to interventions for neurological health, as well as with the NIH
    Neuroscience Blueprint Toolbox initiative on the development of
    assessment tools for cognitive and behavioral health. NIA also
    continues to support studies of age-related changes in cognition,
    including grants funded under two new and related research
    initiatives--one to develop neural and behavioral profiles of normal
    cognitive aging and one to develop interventions to remediate age-
    related cognitive decline as distinct from Alzheimer's disease (AD) or
    related conditions.
        promoting healthy aging and preventing age-related disease and
                                   disability
        NIA is continuing to support the development of interventions to
    maintain health and prevent age-related disease and disability. For
    example, NIA-supported researchers are conducting a number of studies
    aimed at reducing the incidence and severity of falls, the leading
    cause of both fatal and nonfatal injury among older adults in the
    United States. Ongoing studies are exploring the association between
    vitamin D insufficiency and fall risk; examining the effects of
    neighborhood environmental characteristics on risk of outdoor falls;
    and focusing on development of strategies to improve strength, balance,
    and gait in the elderly.
        The NIA-supported Advanced Cognitive Training for Independent and
    Vital Elderly Study was the first randomized, controlled trial to
    demonstrate long-lasting, positive effects of brief cognitive training
    to forestall cognitive decline in older adults. However, the training
    did not improve the participants' ability to tackle everyday tasks.
    More research is needed to translate the findings from the laboratory
    into interventions that are effective at home. In 2008, NIA solicited
    research to convert insights from previous work in cognitive aging into
    feasible intervention strategies, including cognitive training,
    lifestyle interventions, dietary interventions, or behavioral change
    that can be tested in randomized clinical trials. Investigators are
    encouraged to develop interventions addressing the role of individual
    differences in cognition, personality, and sociocultural factors in
    mediating or moderating adherence and outcomes. This research will be
    active in 2010.
        The development of interventions that will extend life span as well
    as health span is another emerging area of study. Through the
    innovative Interventions Testing Program, NIA-supported researchers are
    investigating promising treatments, including diets, pharmaceuticals,
    and nutritional supplements, that have the potential to extend the life
    span and delay disease and dysfunction in mice, with the long-term goal
    of identifying those interventions most likely to have a beneficial
    effect in humans. Fourteen compounds are currently under study, with 3
    more slated to be added in 2009. Testing on these compounds will
    continue through 2010.
        early detection, diagnosis, and treatment of age-related disease
        Improved technologies as well as advances in our understanding of
    the mechanisms of disease are allowing for the development of
    interventions to predict, detect, diagnose, and treat age-related
    disease and disability. Scientists in NIA's groundbreaking Alzheimer's
    Disease Neuroimaging Initiative have made a significant step forward in
    developing a test to diagnose the early stages of AD earlier and more
    accurately by measuring two biomarkers--tau and beta-amyloid proteins--
    in cerebrospinal fluid. The investigators found that certain changes in
    biomarker levels in cerebrospinal fluid may signal the onset of AD.
    They also established a method and standard for testing of these
    biomarkers.
        NIA currently supports more than 30 clinical trials of
    interventions to prevent, slow, or treat AD. Interventions under study
    include a highly promising immune approach; hormonal treatments,
    including testosterone and raloxifene; diabetes drugs such as metformin
    and insulin; antioxidants; physical and mental exercise; commonly used
    psychiatric drugs; and many others. The identification of imaging and
    biological markers as well as the development of improved clinical and
    neuropsychological evaluation methods will enable us to perform less
    expensive, shorter, and more efficient intervention trials.
        In addition, NIA supports studies of treatments for a variety of
    other conditions including new therapies for menopausal hot flashes;
    hormone supplementation in men with symptoms related to low levels of
    testosterone; and cognitive behavioral therapy for older adults with
    arthritis pain and insomnia. A follow-up study to the ground-breaking
    Diabetes Prevention Program established the efficacy of a lifestyle
    intervention and drug treatment that can sharply decrease the risk of
    type 2 diabetes in overweight individuals, which was most pronounced
    for individuals age 60 or over.
          addressing the societal implications of an aging population
        The social and economic implications of aging are multi-faceted.
    NIA supports long-term studies of older Americans covering a wide range
    of topics, including retirement and economic status, care giving,
    behavioral medicine, the dynamics of health and functional change at
    older ages, cognition, and long-term care. These studies include the
    ongoing Health and Retirement Study, the leading source of combined
    data on health and financial circumstances of Americans over age 50 and
    a valuable resource to follow and predict trends and help inform health
    policy. NIA also supports studies on the social, emotional, cognitive,
    and motivational processes and neurobiological mechanisms of economic
    behavior as these influence social, financial, and health-related
    decisions of middle-aged and older adults.
        One of NIA's most urgent priorities is to improve our ability to
    reduce health disparities and eliminate health inequities among older
    adults. NIA works to identify ways to reduce health disparities through
    its Resource Centers for Minority Aging Research, and the Institute has
    compiled a Web-based toolkit on outreach, recruitment, and retention of
    minority populations in clinical research on aging. Through the Healthy
    Aging in Neighborhoods of Diversity Across the Life Span Study, NIA
    intramural researchers are continuing their efforts to disentangle the
    complex relationships among race, socioeconomic status, and health
    outcomes. Other programs, notably the NIA Alzheimer's Disease Centers,
    have a strong focus on minority health and health disparities in both
    research and outreach.
        Once again, thank you. I welcome your questions.
                                     ______

        Prepared Statement of Dr. Kenneth R. Warren, Director, National
                   Institute on Alcohol Abuse and Alcoholism
        Mr. Chairman and members of the subcommittee: I am pleased to
    present the President's fiscal year 2010 budget request for the
    National Institute on Alcohol Abuse and Alcoholism (NIAAA), of the
    National Institutes of Health (NIH). The fiscal year 2010 budget
    includes $455,149,000, which is $4,919,000 more than the fiscal year
    2009 appropriation of $450,230,000.
        NIAAA's long-range vision for medicine with respect to alcohol-
    related health issues is that research on the health effects of alcohol
    will reduce the burden of illness attributable to excessive alcohol
    consumption thereby enhancing the well-being of individuals at risk,
    their families, and society-at-large. Through translation of NIAAA
    supported research findings, we have an unparalleled opportunity to
    significantly reduce the burden of illness due to alcohol-related
    problems. We are especially appreciative of the American Recovery and
    Reinvestment Act funds which will accelerate our progress. NIAAA's
    budget request and its research projects are consistent with the
    President's multi-year commitment for cancer and autism.
                   current scope of the problem and research
        According to the Centers for Disease Control and Prevention,
    alcohol is the third leading cause of preventable death in the United
    States. Even more important from a public health perspective, alcohol
    misuse negatively affects the quality of life for millions of
    Americans. According to the World Health Organization, alcohol is one
    of the top 10 causes of Disability Adjusted Life Years in the United
    States and contributes to a number of the other leading causes. Alcohol
    problems cost the United States an estimated $185 billion annually,
    with almost half the cost resulting from lost productivity due to
    alcohol-related disabilities.\1\ According to NIAAA's National
    Epidemiological Survey on Alcohol and Related Conditions, more than 18
    million people ages 18 and older suffer from alcohol abuse or
    dependence and only 7 percent of them receive any form of treatment.
    Furthermore, heavy drinkers, who are not dependent, but nevertheless at
    risk for adverse health and psychosocial outcomes, are seldom
    identified. The consequences of alcohol misuse can affect both drinkers
    and those around them at all stages of life, from damage due to alcohol
    exposure of the developing embryo, to injuries, to tissue and organ
    damage resulting from chronic, heavy alcohol use. Therefore, to achieve
    its goal of reducing the heavy burden of illness from alcohol misuse,
    NIAAA's research focus must be broader than simply reducing alcohol-
    related mortality; it must encompass reducing the risk for all adverse
    alcohol-related outcomes at all stages of life.
    ---------------------------------------------------------------------------
        \1\ Harwood, H. Updating Estimates of the Economic Costs of Alcohol
    Abuse in the United States: Estimates, Update Methods and Data (2000).
    ---------------------------------------------------------------------------
        Research supported by NIAAA has reframed our understanding of
    alcohol dependence in several ways by demonstrating that: (1) it is a
    developmental disorder that often has its roots in childhood and
    adolescence; (2) the highest prevalence of alcohol dependence in the
    U.S. general population occurs in 18-24 year olds; (3) there is
    substantial variation in the severity and chronicity of dependence
    among individuals; and (4) a large percentage of individuals with
    alcohol dependence are highly functional in society, and therefore go
    largely unnoticed by the healthcare system.
        These findings underscore the opportunity to: (1) be able to better
    predict which individuals are at risk for future dependence by
    understanding the complex interplay between genetic, environmental, and
    developmental factors; (2) pre-empt future problems through research-
    based prevention efforts for children and adolescents as well as
    screening and guidance for people of all ages about how drinking
    patterns, especially binge drinking, relate to adverse health outcomes;
    (3) conduct research to develop treatment options that are personalized
    to individual needs and lifestyles; and (4) engage individuals,
    communities, and professional groups to be actively participatory in
    shaping the future of healthcare as it relates to alcohol misuse.
                             outlook for the future
        NIAAA is revolutionizing alcohol treatment by providing evidence-
    based options for addressing the full range of alcohol- related
    problems. For example, research has shown the value of alcohol
    screening in primary care and mental health settings to help patients
    understand the risks associated with different drinking patterns. NIAAA
    has developed tools that clinicians can use to screen and intervene in
    these settings. Moving treatment of less severe forms of alcohol
    dependence into mainstream medical care will decrease stigma, improve
    availability, accessibility, and appeal of treatment options, and
    ultimately reduce the number of people who suffer with dependence.
    Alcohol-dependent patients will benefit from NIAAA's research focusing
    on the development of new treatments including behavioral therapies and
    medications that will shorten the duration, number, and severity of
    episodes of dependence and prevent, for most, the development of
    chronic, relapsing dependence. Studies suggest that as a result of
    these types of intervention, most people with mild to moderate
    dependence will recover.
        Patients with more severe and/or relapsing dependence, are more
    complex to treat and often need multi-faceted, personalized addiction
    services that may include medications, counseling, psychotherapy, and
    case management. These patients often have other health (infectious
    diseases, mental illness, and liver disease) and psychosocial (family,
    marital, and workplace) problems, some that are the direct result of
    their alcohol misuse. Comprehensive treatment must take all of these
    into account. NIAAA-supported research will continue to develop and
    refine treatment options for these individuals, both for their alcohol
    dependence as well as the many adverse health consequences that may
    result. Collectively, these changes in the approach to treatment of
    alcohol problems will substantially reduce the public health burden of
    heavy drinking and alcohol use disorders.
        Ensuring that appropriate research-based guidance about alcohol use
    for special populations, including pregnant women, is available and
    will result in a dramatic reduction in the incidence of fetal alcohol
    spectrum disorders, the most severe forms of which produce lifelong
    disability, and may also decrease the incidence of Sudden Infant Death
    Syndrome. NIAAA research will continue to inform this guidance,
    including information about the risks of alcohol exposure to the
    developing embryo and fetus, and will make it accessible to primary
    healthcare providers and obstetricians. For pregnant women who drink
    despite the best advice, research is focused on developing nutritional
    and/or pharmacological agents that may lessen the negative effects of
    alcohol exposure.
        Biomarkers, stemming from NIAAA-supported genetic and epigenetic
    research, will be available that: (1) predict individual risk for
    future alcohol dependence; (2) assess progression of at risk drinking
    through dependence; and (3) track damage to tissue and organs. These
    tools will enhance the ability of healthcare providers to offer
    guidance to patients about their drinking patterns and determine
    appropriate healthcare based on individual risk factors. A repertoire
    of medications will facilitate treatment tailored to the needs of the
    patient. Personalized treatment including medications and behavioral
    therapies will be based on individual genetic make-up, desired drinking
    outcomes, attention to co-occurring disorders, ease of compliance, and
    other factors.
                                 moving forward
        NIAAA supported biomedical and behavioral research is supporting
    the research that will contribute to realizing the vision outlined
    above. Ongoing studies, as well as new initiatives, will provide the
    scientific knowledge and tools, to improve our ability to predict which
    individuals are at increased risk for alcohol-related problems
    including dependence, pre-empt the harm from alcohol misuse, and
    provide personalized treatment.
        The integration of routine alcohol screening, and where
    appropriate, brief intervention and/or referral to specialty treatment
    into primary healthcare for all ages is central to reducing
    consequences of alcohol misuse. NIAAA will continue to develop teaching
    and training tools to increase the usage of A Clinician's Guide:
    Helping Patients Who Drink Too Much. NIAAA has also recently launched
    Rethinking Drinking, a new Web site, and booklet that provides
    information and tools to help individuals change harmful drinking
    patterns, either on their own or by helping them reach the decision to
    seek help. NIAAA is also developing guidance on screening and brief
    intervention for children and adolescents, recognizing that criteria
    developed for adults may not fit the needs or behaviors of youth.
        Medications development remains a central focus of the Institute.
    Emerging data are changing the way we look at alcohol dependence,
    guiding us to be more strategic about the medications we test, the way
    we test and design them, and how we determine the subpopulations of
    patients most likely to benefit from them. For example, new
    understanding of the relationship between withdrawal induced anxiety
    and relapse has provided additional targets for drug development to
    minimize relapse. Broadening the desired treatment outcome, from
    targeting only abstinence to including reduction in heavy drinking, is
    also influencing the medications that are being tested as well as how
    they are tested. Other compounds that may mitigate tissue and organ
    damage are under study.
        Most individuals with alcohol dependence do not access treatment
    yet many of them recover without the benefit of professional care or
    facilitated self-help. NIAAA continues to investigate the process
    leading to a decision to stop drinking or to seek help. In concert with
    a broader NIH Roadmap Initiative, NIAAA is currently supporting studies
    to understand mechanisms of change away from harmful health behaviors.
        Given our current state of knowledge and what we are learning from
    ongoing studies, we are optimistic that we can substantially reduce the
    burden of illness for alcohol-related problems and the suffering it
    brings to individuals, their families and society at large.
                                     ______

    Prepared Statement of Dr. Stephen I. Katz, Director, National Institute
               of Arthritis and Musculoskeletal and Skin Diseases
        Mr. Chairman and members of the subcommittee: I am pleased to
    present the President's fiscal year 2010 budget for the National
    Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) of
    the National Institutes of Health (NIH). The fiscal year 2010 budget
    includes $530,825,000, which is $5,953,000 more than the fiscal year
    2009 appropriation of $524,872,000.
                                  introduction
        As the primary Federal agency for supporting medical research on
    diseases of the bones, joints, muscles, and skin, the NIAMS touches the
    lives of nearly every American. For example, the U.S. Bone and Joint
    Decade notes that 1 in 2 people will experience back pain each year,
    and 1 in 5 will have pain that affects their ability to work. The
    National Arthritis Data Working Group estimates that 21 percent of
    adults have arthritis in at least one joint, a figure that is likely to
    grow as the population ages. Likewise, 1 of every 2 women and 1 in 4
    men aged 50 years and older suffer fractures each year because of
    osteoporosis; researchers project that the number of osteoporotic
    fractures in the United States will grow from 2 million to more than 3
    million in the next two decades. The NIAMS is committed to preventing
    disabilities and reducing costs associated with these and other
    conditions through balanced basic, translational, and clinical research
    investments.
        As the Institute sets priorities, it is considering how recent
    advances have positioned its research community for discoveries to
    prevent disease and improve each American's life. It is soliciting
    input from researchers, healthcare providers, patients, and the public
    on promising areas of inquiry; pressing scientific needs; programs to
    ensure a continuing supply of well-trained researchers; and strategies
    to eliminate health disparities. An important consideration is how
    investigators can engage in multidisciplinary opportunities. Chronic
    pain, for example, is an aspect of many diseases that are part of the
    NIAMS portfolio; staff are exploring partnerships through the Trans-NIH
    Pain Consortium. Prospects for stem cell research are growing rapidly
    as researchers isolate stem cells from skin and other organs, and as
    more lines become available under the Nation's policy for Federal
    support of embryonic stem cell research.
        Consistent with the Federal commitment to double NIH-wide cancer
    research spending, the NIAMS will continue to pursue collaborations
    with the National Cancer Institute in support of high-quality projects
    that relate directly to diseases and organ systems within the NIAMS
    mission, particularly the bones and the skin. Already, the NIAMS
    supports research on mechanisms underlying skin cancers, and
    investigators have uncovered a strategy that kills tumor cells with
    less damage to healthy skin.
                              preventive medicine
        Research to identify susceptibilities to and initial symptoms of
    disease, and to develop strategies to slow disease progression, is a
    NIAMS priority. Building on findings that early, aggressive therapy
    alters the course of rheumatoid arthritis (RA), NIAMS is comparing
    treatments against a related disease-juvenile idiopathic arthritis.
        The NIAMS and the National Institute on Aging lead the
    Osteoarthritis Initiative (OAI), a public-private partnership to
    identify and evaluate biomarkers of osteoarthritis (OA). NIH and its
    partners, with input from the Food and Drug Administration, launched
    the OAI in 2001. More than 1,100 researchers worldwide have accessed
    OAI data to explore issues such as differences in OA progression, or
    why only some people with X-ray evidence of OA develop pain. In 2010,
    the NIH will extend the OAI for 6 years. It expects the OAI to suggest
    approaches for slowing joint damage, facilitate clinical testing of
    interventions and allow clinicians to identify risk factors for OA
    development, predict severity, and personalize treatments for their
    patients.
                            complex genetic diseases
        The NIAMS community is benefiting from another public-private
    partnership, the Genetic Association Information Network (GAIN). Since
    GAIN's inception, NIAMS investigators have been involved in its
    Collaborative Association Study of Psoriasis, an ambitious effort to
    combine genetic and clinical information from people affected by
    psoriatic skin disease and psoriatic arthritis. The project has yielded
    a wealth of data that researchers are using to develop diagnosis,
    treatment, and prevention strategies.
        NIAMS-funded investigators have uncovered genetic susceptibility
    markers of alopecia areata and other autoimmune or auto-inflammatory
    skin and joint diseases, including lupus. Collaboration among United
    States and European researchers recently linked a component of the
    immune system and RA. At the NIH Clinical Center, sample collection has
    begun for a genomic analysis of Behcet's disease, a complex disorder of
    inflammation affecting skin, eyes, gastrointestinal tract, lungs,
    vasculature, and joints.
                        collaborations and team science
        Behcet's disease is one of many conditions researchers are studying
    through the new NIH-wide Center for Human Immunology, Autoimmunity, and
    Inflammation. NIAMS' intramural program is taking a leadership role in
    the Center. Collaborations among scientists from several NIH Institutes
    who are studying related disease systems will facilitate studies about
    conditions associated with defective immune or inflammatory responses,
    and will allow them to apply their results to the development of
    interventions and, ultimately, disease prevention strategies.
        In collaboration with orthopaedic surgeons at the Walter Reed Army
    Medical Center, NIAMS researchers recently discovered that tissue
    commonly discarded as waste contains special cells that feature many of
    the same properties as adult stem cells. The cells can be used for
    regenerative medicine, such as treating war-traumatized muscle, without
    subjecting patients to additional surgeries and related complications.
        The NIAMS participates in the multi-Institute Senator Paul D.
    Wellstone Muscular Dystrophy Cooperative Research Centers program. In
    addition to conducting research, scientists at the Centers maintain
    core resources that all who are studying muscular dystrophy can use. A
    group of NIAMS-funded muscle researchers showed that defects in blood
    vessel constriction are associated with the severe fatigue that people
    with muscular dystrophy experience; mouse experiments suggest that
    compounds with FDA-approval for other conditions may improve symptoms.
    Other scientists uncovered molecules that confer many of the benefits
    of exercise, at least in mice; the findings might lead to treatments
    for conditions that leave patients unable to exercise.
        The scale and complexity of today's research problems and their
    solutions demand that the NIH explore new models for team science. In
    fiscal year 2008, the NIAMS started a program, Building
    Interdisciplinary Research Teams (BIRT), to promote partnerships among
    fields that share interests, but historically do not interact. Because
    collaborations proposed in the first round of applications suggested
    that modest investments in the program will provide great dividends,
    the NIAMS opened BIRT up to additional communities and expects to make
    another set of awards at the end of fiscal year 2009.
        In the past year, the NIAMS has made considerable progress in
    leading a trans-NIH partnership with the National Aeronautics and Space
    Administration. By designating the U.S. portion of the International
    Space Station (ISS) as a National Laboratory, Congress underscored the
    significance that Americans place on the ISS' research potential. The
    NIH shares this belief and, for the next 3 years, will accept
    applications for studies that use the ISS for experiments directly
    related to the NIH goals of understanding human physiology and
    promoting the public's health.
                                clinical studies
        One element of improving the Nation's health is to support clinical
    studies on which physicians can rely when discussing treatment options
    with patients. Before the Spine Patient Outcomes Research Trial
    (SPORT), many who had low back pain were conflicted about surgery. Now,
    patients can be assured that surgery relieves pain from herniated
    disks, but--if the pain is tolerable and not worsening--it will likely
    subside without surgery. Similarly, people who have pain due to spinal
    stenosis (a narrowing of the spinal column that occurs with age) are
    likely to benefit more from surgery than from noninvasive treatments
    such as physical therapy; but, they are not causing more damage if they
    adopt a ``wait-and-see'' approach before committing to an operation.
    Recently, SPORT offered guidance to help people who suffer from
    herniated disks personalize their treatment decisions by reporting that
    study participants who had surgery on an upper lumbar disk improved
    more than those with damage further down.
        For decades, the NIAMS has invested heavily in efforts to
    understand fracture risk and to uncover strategies to prevent and treat
    bone loss. Although physicians now have an array of medications for
    people who are at risk of osteoporosis, many patients fail to benefit
    fully because they do not follow the treatment regimens. Because a
    method to improve compliance could immediately slow the growing health
    and economic burden that osteoporosis places on society, the NIAMS is
    funding research in this area.
                                   conclusion
        The discoveries and activities highlighted above are just a few
    examples of research that will continue to benefit Americans from all
    walks of life. In partnership with Government and private entities, the
    NIAMS also develops and distributes science-based health information
    directly to patients, healthcare providers, and the public. The
    Institute will continue outreach to diverse populations through
    research, training, and information dissemination. Collectively, NIAMS
    programs have spurred understanding of many common, chronic, and costly
    diseases. Looking forward to the next decades, this progress provides a
    foundation for an era in which the burden of these debilitating
    conditions is reduced and--with time, continued support from the
    American public, and the dedication of our Nation's researchers--
    eliminated for millions of affected adults, children, and families.
                                     ______

      Prepared Statement of Dr. Roderic I. Pettigrew, Director, National
               Institute of Biomedical Imaging and Bioengineering
        Mr. Chairman and members of the subcommittee: I am pleased to
    present the President's fiscal year 2010 budget request for the
    National Institute of Biomedical Imaging and Bioengineering (NIBIB) of
    the National Institutes of Health. The fiscal year 2010 budget includes
    $312,687,000, which is $4,479,000 more than the fiscal year 2009
    appropriation of $308,208,000.
        The NIBIB is leading the development of revolutionary technologies
    that will help transform medicine in the United States and around the
    world. It has primary responsibility for uniting the engineering and
    physical sciences with the life sciences to bring about new ways of
    thinking that will accelerate discovery and technology development.
    With a global vision and a public health mission, the Institute is
    working to develop technologies that enable personalized healthcare,
    early detection of disease, and treatments that are minimally invasive,
    cost-effective and widely accessible.
                      translating technology into practice
        Ultimately, NIBIB seeks to expand the translation of technological
    advances into solutions that improve human health by reducing disease
    and enhancing quality of life. To accomplish this goal, NIBIB continues
    to fund bold and far-reaching projects that facilitate discovery and
    translate discovery to clinical practice. NIBIB-supported scientists in
    the innovative Quantum Grants Program are making extraordinary progress
    to develop new technologies and modalities for the diagnosis,
    treatment, or prevention of disease that will result in practical
    healthcare benefits for the Nation.
     changing healthcare delivery through point-of-care (poc) technologies
        Testing at the point of initial contact, or ``point-of-care,''
    rather than at specialized centers or hospitals utilizes state-of-the-
    art diagnostics and information systems that can be used in the
    doctor's office or even at home. Consequently, the use of POC devices
    can also help patients monitor their wellness in preventive medicine.
    The POC approach to health care delivery can significantly improve the
    quality and reduce the cost of health care by: providing earlier
    diagnosis of disease when treatment is more effective and less costly;
    making modern medicine available to those who lack access to regular
    care, such as people in rural settings or developing countries;
    combining cutting-edge diagnostic and communication technologies to
    bring patients into more frequent and regular contact with health care
    providers; and enabling a patient-centered process with home-based
    monitoring.
        The NIBIB currently funds a network of four POC Technologies
    Research Centers that target the development of new POC technologies
    for early and rapid detection of strokes, detection of sexually
    transmitted diseases, rapid multi-pathogen detection for national
    disaster readiness, and diagnosis of infections that can be used in
    low-resource settings among underserved populations. Additionally, the
    NIBIB and the Department of Biotechnology (DBT) of the Ministry of
    Science and Technology of the Republic of India held a joint workshop
    on Low-Cost Diagnostic and Therapeutic Medical Technologies in November
    2008 in Hyderabad, India. The workshop was a result of a bilateral
    agreement between the NIBIB and DBT to develop low-cost technologies to
    improve the quality of healthcare for underserved populations. Point-
    of-care testing is becoming a vital part of the world's healthcare
    delivery system, and is a key to reducing healthcare costs while
    maximizing accessibility for everyone.
                         health information technology
        Health information technology research that enables the integration
    of clinical data, medical image diagnostic and treatment data with the
    patient's medical history in a comprehensive electronic medical record
    will improve clinical decisionmaking. The ability to connect and
    exchange diagnostic information and medical images between healthcare
    providers, clinics, and hospitals will help provide the timely
    information that is needed for effective healthcare and will help
    reduce unnecessary, excessive, and duplicative procedures. A patient-
    centered approach to comprehensive electronic health records will allow
    patients access to their health information. This will enable patients
    to play an active role in their own wellness by enabling them to ask
    knowledgeable questions about treatment options. Additionally, patients
    are also empowered to provide this information to any and all
    healthcare providers as needed, independent of their location or where
    the medical data was created or stored. The NIBIB supports research in
    new technologies to address issues such as: interoperability of data
    systems, compatibility of computer software across medical
    institutions; security of data during transmission; HIPPA compliance;
    and availability of affordable data systems for patient care providers.
               microchip captures early circulating cancer cells
        NBIB's budget request and its research projects are consistent with
    the President's multi-year commitment for Cancer. Malignant cancers
    shed cells that enter the circulation, travel to other areas of the
    body, and often grow into secondary tumors, or metastases. Indeed,
    metastases are responsible for the great majority of cancer deaths. It
    is estimated that 70,000 men per year are diagnosed with recurrent
    prostate cancer after prostatectomy, as shown by rising prostate
    surface antigens. For these men, the ability to detect and characterize
    the malignant cells in the blood may enable personalized therapy.
    Researchers are developing a technology to facilitate quantitative
    detection of circulating tumor cells (CTCs). They have engineered a
    microchip with a large surface area of an adhesion molecule that binds
    CTCs from whole blood, making detection of CTCs more reliable than
    previous approaches. They are analyzing molecular and genomic
    information in the CTC's to identify new biomarkers to customize
    treatments that are personalized for the patients and to predict
    treatment outcomes. The NIBIB-supported research has the potential to
    eliminate or greatly reduce cancer deaths due to metastases.
              regenerating brain tissue to promote stroke recovery
        Brain cells can be irreversibly damaged in a matter of minutes when
    the blood supply carrying oxygen and glucose is interrupted in a
    stroke. Individuals who have had a stroke may experience partial
    paralysis or problems with awareness, attention, learning, judgment,
    memory, or speech. An international team of researchers from Baylor
    College of Medicine, Rice University, London's National Institute of
    Medical Research, King's College of London, and Edinburgh University is
    integrating cutting-edge imaging, biological, and engineering
    techniques to map and understand normal brain regions that are
    responsible for generation of new neurons in the adult. The ultimate
    goal is to bioengineer a cellular system mimicking these brain regions
    that can eventually be used to replace and/or drive repair of stroke-
    damaged tissue.
           miniature artificial kidney replaces traditional dialysis
        Nearly one-half of a million people in the United States suffer
    from end-stage renal disease (ESRD), and the incidence rate of this
    disease has been steadily increasing for over 25 years. Kidney
    transplantation provides the best option for ESRD patients, but a
    shortage of donors means that most patients never make it to the top of
    a waiting list. The alternative is dialysis, which is expensive,
    inconvenient, far less effective, and significantly lowers the
    patient's quality of life. An interdisciplinary group of researchers
    has envisioned a way to improve management of ESRD by developing an
    implantable, self-regulating, bioartificial kidney capable of filtering
    toxins from the blood as well as replacing some of the metabolic
    functions of a healthy kidney. Such an implantable bioartificial kidney
    could substitute for transplantation and will truly be a quantum leap
    in healthcare, giving hope, independence, and mobility to the 350,000
    patients presently tethered to thrice-weekly in-center dialysis.
     insulin-producing cells from amniotic fluid stem cells treat diabetes
        More than 1 million people in the United States suffer from type 1
    diabetes, which is caused by the destruction of insulin-producing
    pancreatic islet cells. Currently available insulin therapy by itself
    does not cure the disease or prevent many of its long-term
    complications. Transplantation of islet cells has shown promise, but
    there is a shortage of donors, and the process is expensive,
    inefficient, and requires life-long immunosuppression. Researchers from
    Wake Forest University and the University of Miami have combined their
    expertise in stem cell differentiation and in vivo islet cell
    transplant studies to explore a new approach using amniotic fluid stem
    cells. The team has successfully isolated amniotic fluid stem cells and
    generated insulin-producing, islet-like cells in vitro. Future work
    will determine whether these cells are able to function and survive in
    animal models of diabetes. If successful, this approach could
    potentially provide a curative treatment for type 1 diabetes through
    transplantation using cells produced from amniotic stem cells.
        molecular theranostics: new technologies for the diagnosis and
                             treatment of diseases
        The concept of combining a therapeutic with a diagnostic agent is
    rapidly evolving and goes beyond traditional diagnostic tests that
    screen or confirm the presence of a disease. With specialized molecular
    imaging techniques and biomarkers, theranostics might predict risks of
    disease, diagnose disease, and monitor therapeutic response leading to
    real-time, cost-effective treatment. NIBIB supports a number of teams
    that are developing novel theranostics and approaches that can be
    applied in clinical studies of human patients. A team of chemists and
    neurosurgeons at the University of Michigan is developing highly
    specific, dye-loaded nanoparticles capable of delivering targeted
    photosensitizers to improve the survival of brain tumor patients. This
    technique will allow neurosurgeons to visualize the brain tumors for
    surgical resection of the main tumor mass while eradicating remaining
    tumor cells through a process known as photodynamic therapy. These
    particles also contain imaging contrasting agents to visualize response
    to therapy.
                                     ______

    Prepared Statement of Dr. Nora D. Volkow, Director, National Institute
                                 on Drug Abuse
        Mr. Chairman and members of the subcommittee: I am pleased to
    present the President's fiscal year 2010 budget request for the
    National Institute on Drug Abuse (NIDA) of the National Institutes of
    Health (NIH). The fiscal year 2010 budget includes $1,045,384,000,
    which is $12,625,000 more than the fiscal year 2009 appropriation of
    $1,032,759,000.
        Drug abuse and addictions are preventable conditions, yet continue
    to cause immeasurable human suffering, with associated societal costs
    estimated to exceed one-half a trillion dollars annually in the United
    States. Tobacco use alone is responsible for more than 400,000 deaths
    per year, and is the leading cause of preventable death in the United
    States. NIDA's budget request and its research projects are consistent
    with the President's multi-year commitment for cancer. For example,
    NIDA has active programs to hasten the development of new, more
    effective treatments for nicotine addiction that can dramatically
    reduce the prevalence of diseases like lung cancer and emphysema, which
    mean an early death for many smokers. Other NIDA-supported research
    advances have contributed to steady declines in both licit and illicit
    drug use over the years, particularly among our Nation's youth. Our
    latest Monitoring the Future (MTF) survey of drug use patterns and
    trends among 8th, 10th, and 12th graders reveals, for example, that
    tobacco use has declined continuously since its peak in the mid-1990s,
    and is presently at its lowest level since the first MTF survey in
    1975. However, if we are to fully eradicate drug abuse and addictions,
    we must find novel approaches to prevent drug abuse (including smoking)
    among the significant fraction of youth who, because of strong genetic
    and/or environmental propensity, appear refractory to current efforts.
    Additional challenges include the growing abuse of prescription
    medications, including opioid analgesics (e.g., painkillers),
    stimulants (e.g., ADHD medications), and CNS depressants (sleep and
    anxiety medications). NIDA is committed to closely monitoring these
    trends and to furthering the development of innovative strategies to
    counter them, including the widespread dissemination of screening and
    early intervention tools for medical settings to increase the medical
    community's participation in identifying and treating substance abuse
    disorders.
            addiction medications: changing the culture of treatment
        NIDA's accelerating rate of discovery is beginning to spur the
    advent of better medications and behavioral interventions to counteract
    drug-induced changes in brain function. Among the strategies NIDA
    supports for medications development are those to: counter stress
    responses, which frequently trigger relapse to drug use; strengthen
    executive function and inhibitory control so that drug abusers can
    better control their urge to take drugs; and interfere with drug-
    conditioned memories to prevent relapse when drug abusers are exposed
    to environments they associate with drug use. Other research includes
    development of vaccines, or antibody-based approaches, which can block
    both illicit and licit drugs (e.g., nicotine) from ever reaching the
    brain, thereby inhibiting their rewarding effects. In the context of
    nicotine addiction, this approach may help prevent smokers from
    escalating to addiction and/or facilitate abstinence in those who seek
    to quit. It also complements ongoing efforts to discover new, more
    effective medications through conducting screens of novel compounds and
    chemical libraries and applying promising findings to help people
    achieve abstinence from tobacco and other addictive substances.
        To accelerate progress in combating substance use disorders, there
    must also be social change to recognize that people who suffer from
    addiction require medical treatment. Presently, addiction treatment
    occurs largely outside of mainstream medicine, even though drugs
    undermine overall health, frequently appearing alongside other medical
    and psychiatric conditions. To help change this culture, NIDA is
    providing knowledge of associated brain dysfunctions and developing and
    deploying effective addiction medications. As these efforts succeed,
    the consequent medicalization of drug abuse and addiction will allow
    (1) clinicians to respond to their patients' needs more effectively and
    in a more personalized fashion; (2) insurance companies to become
    increasingly responsible for the coverage of treatments that can
    dramatically improve overall health; and (3) pharmaceutical companies
    to be incentivized to develop novel addiction medications. As the
    stigma of addiction wanes, the dissemination of proven treatments will
    expand to include the populations that need them the most, such as
    those involved in the criminal justice system, half of whom meet the
    criteria for drug abuse or dependence, according to estimates from the
    Department of Justice. Broader treatment access for drug-addicted
    offenders will help them to successfully transition back into society,
    dramatically reducing not just drug abuse, but also criminal
    recidivism.
                  genes and environment: high pay-off research
        A steady flow of genetic discoveries is uncovering previously
    unsuspected genes whose products may be involved in the addiction
    process and therefore present good candidates for medication
    development. They also herald the advent of more personalized
    interventions based on a patient's genetic profile. And, because genes
    influence both vulnerability and resilience to substance abuse and
    other mental disorders, genetic data will further our understanding of
    the basic mechanisms underlying the disease of addiction, as well as
    its frequently associated comorbid conditions.
        But genes do not act in isolation; rather, they work in tandem with
    developmental and environmental factors to determine a person's drug
    abuse vulnerability. Therefore, NIDA is encouraging more research to
    understand how genes might mitigate or amplify social influences that
    affect individual choices and behaviors related to substance abuse.
    Conversely, environmental elements, such as parenting quality, home
    conditions, stress, diet, pollutants, and, of course, exposure to drugs
    of abuse, can regulate gene expression. Uncovering the mechanisms
    behind these so called epigenetic effects, offers a path to alleviate
    and perhaps even override a genetic predisposition by adjusting
    environmental variables.
        One approach NIDA is pursuing is the merging of genomic and brain
    morphology (i.e., brain structure) data in order to understand how
    genes influence human brain development. Such data would be invaluable
    as a basis for understanding the contribution of specific genes to
    neuropsychiatric disorders and how exposure to certain environmental
    factors can trigger disease in those who are genetically vulnerable.
    This research would, in turn, open the door to next-generation
    pharmaceuticals that could target and perhaps even prevent or reverse
    disease processes. The recent discovery of histone demethylases--a new
    family of genome modifying enzymes--is just one example of a set of
    proteins that could be targeted for medications development.
        Also critical to substance abuse prevention and treatment is the
    development of reliable assays for drug exposure and addiction
    vulnerability. Although tests of bodily fluids or hair and surveys
    using self-report questionnaires are used routinely, their value is
    compromised by their limited reliability, low sensitivity, and narrow
    scope. NIDA will encourage research to find reliable biomarkers--or
    indicators of a biological response/vulnerability to drug exposure--for
    assay development. The ability to quantify thousands of biomarkers in a
    consistent, expeditious, and affordable manner will yield revolutionary
    new approaches to the prevention and personalized treatment of
    substance abuse.
                the relevance and impact of comorbid conditions
        NIDA research has demonstrated that drug abuse cannot be treated in
    isolation from associated concerns, such as criminal behavior, mental
    and physical health status, social functioning, and HIV/AIDS. A robust
    and consistent effort to tap into and integrate different sources of
    knowledge will be needed to design and implement effective
    interventions in the future. This will be particularly important for
    members of the military and their families, who may be facing difficult
    challenges related to substance abuse in the coming years. Many are
    returning from active duty with post-traumatic stress disorder (PTSD)
    and/or chronic pain conditions, both of which can be comorbid with drug
    abuse and require comprehensive treatment interventions. In response to
    these projections NIDA will increase our research investment in this
    area and collaborate with the Veteran's Administration, the Substance
    Abuse and Mental Health Administration (SAMHSA), and other NIH
    Institutes--NIMH, NCI, NIAAA, and NHLBI--in developing a responsive and
    forward-looking research agenda.
                understanding the dynamics of drug abuse and hiv
        NIDA's recent revamping of its HIV/AIDS research strategy better
    addresses the critical need for new therapies for drug abusers with HIV
    and for research designed to uncover more about the complex medical
    consequences, such as neuroAIDS. Initiatives in this area will help
    elucidate the effects of genetic variations on disease progression, and
    on how drugs of abuse and medications (for drug addiction and HIV)
    interact with both host and viral genes. To further such innovations,
    NIDA has established the Avant-Garde Award for exceptionally creative
    researchers offering transformative approaches to major challenges in
    biomedical and behavioral research on drug abuse and HIV/AIDS. Awardees
    are undertaking diverse approaches, such as evaluating the
    effectiveness of expanded access to highly active antiretroviral
    therapy in decreasing new cases of HIV infection among injection drug
    users. Evidence to date suggests the utility of this approach for
    injection drug users and their partners; if widely adopted, it could
    also help stem the HIV epidemic around the world. In addition, NIDA is
    promoting research on HIV screening and on how to best integrate
    testing and counseling into drug abuse treatment settings, among
    criminal justice populations, and in other countries that have been hit
    especially hard by the epidemic. Learning one's HIV-positive status
    reduces risk behaviors and, when linked to HAART, makes the person a
    less efficient vector for spreading the disease.
        In sum, the health of our Nation and its leadership role in
    bringing science to bear on drug abuse and addiction depend on our
    ability to continue to support promising biomedical research that can
    bring with it enduring and transformative public health changes not
    just to this country but to the rest of the world. Thank you for this
    opportunity, and I will be pleased to answer any questions you may
    have.
                                     ______

      Prepared Statement of Dr. James F. Battey, Jr., Director, National
            Institute on Deafness and Other Communication Disorders
        Mr. Chairman and members of the subcommittee: I am pleased to
    present the President's fiscal year 2010 budget request for the
    National Institute on Deafness and Other Communication Disorders
    (NIDCD) of the National Institutes of Health (NIH). The fiscal year
    2010 budget includes $413,026,000, which is $5,767,000 more than the
    fiscal year 2009 appropriation of $407,259,000.
        The NIDCD conducts and supports research and research training in
    the normal and disordered processes of hearing, balance, smell, taste,
    voice, speech, and language. Last year, NIDCD celebrated its 20th
    anniversary. Over the past two decades, extraordinary research
    opportunities have led to scientific breakthroughs in the study of
    genes, proteins, sensory and supporting cells, and molecular processes
    that directly affect our understanding of communication disorders.
    NIDCD-supported scientists have also made substantial progress in
    behavioral studies that increase our understanding of how communication
    processes impact health. NIDCD's budget request and its research
    projects are consistent with the President's multi-year commitments to
    cancer and autism research. The following are notable research
    highlights built upon two decades of NIDCD support.
                             hair cell regeneration
        Our ability to hear relies on sensory cells in the inner ear,
    called hair cells. Hair cells can be damaged by disease, injury, aging,
    or exposure to certain drugs. When enough hair cells are damaged, an
    individual experiences hearing loss. Although fish, amphibians, and
    birds can spontaneously regenerate new hair cells to replace damaged
    ones, mammals (including humans) cannot. NIDCD-supported research into
    the development of the mammalian inner ear has led to a better
    understanding of which cells in a developing embryo become hair cells,
    and which become supporting cells that help maintain the hair cells.
    These basic studies have provided the foundations for more recent
    advances. For example, NIDCD-supported scientists have identified
    specific genes that determine an inner ear hair cell's fate. Building
    on these studies,
        NIDCD-supported scientists were able to regenerate new hair cells
    in laboratory mammalian animal models, and restore hearing in some
    cases. These promising results provide hope that we might someday be
    able to regenerate functioning hair cells in humans.
                     preventing noise-induced hearing loss
        Prevention of noise-induced hearing loss is another important goal
    for the NIDCD. Approximately 15 percent of Americans between the ages
    of 20 and 69--an estimated 26 million American adults--have high-
    frequency hearing loss caused by exposure to loud sounds or noise at
    work or during leisure activities. Since the sensory hair cells of the
    inner ear do not spontaneously regenerate in humans, preventing noise
    damage to these cells is critical for long-term health. In October
    2008, NIDCD launched a new public education campaign called ``It's a
    Noisy Planet. Protect Their Hearing.'' The campaign is designed to
    increase awareness among parents of children ages 8 to 12--or
    ``tweens''--about the causes and prevention of noise-induced hearing
    loss. With this information, parents and other adults can encourage
    children to adopt healthy habits that will help them protect their
    hearing for life.
       improving technologies to treat hearing loss and balance disorders
        The NIDCD supports many research efforts to develop or improve
    technologies for the treatment of hearing loss and balance disorders.
    The cochlear implant is an electronic device that provides a sense of
    sound to individuals who are profoundly deaf or severely hard-of-
    hearing. Cochlear implants process sounds from the environment by
    directly stimulating the auditory nerve, bypassing the malfunctioning
    cells in the inner ear. Sustained NIH support has greatly improved this
    technology so that, with the appropriate training and support, deaf and
    severely hard-of-hearing individuals who receive a cochlear implant can
    enjoy an enhanced quality of life by participating more fully in
    society. Currently, cochlear implants are most successful in children
    who receive them at a young age, when the brain is still in an active
    phase of language development. NIDCD-supported scientists are
    investigating the benefits of bilateral cochlear implantation, in which
    a cochlear implant is fitted into both ears. Results show that
    individuals receiving two cochlear implants are significantly better at
    localizing sounds and hearing speech in a noisy room compared to
    individuals with one implant. In addition, within 1 to 2 years after
    implantation, children with two cochlear implants will have learned how
    to locate sounds, and most will be able to localize sounds better than
    children with only one implant.
        Much like hearing, our sense of balance relies on hair cells
    arranged in specialized structures within the inner ear, which together
    make up our vestibular system. Vestibular hair cells are susceptible to
    damage by the same mechanisms as hearing hair cells--drugs, trauma, and
    infection--and their dysfunction can lead to dizziness or balance
    problems. Building on lessons learned from cochlear implant research
    and technology, NIDCD-supported scientists are now working to develop
    an implanted device to help partially restore a person's sense of
    balance. Although the prototype vestibular implant is still being used
    in animal studies, it has the potential to benefit more than 90 million
    Americans who experience dizziness or balance problems in the future.
        NIDCD also actively supports research to improve hearing aid
    technology. Improving hearing in noisy environments is a major
    challenge for hearing aid users. Of the currently available
    technologies, directional microphones that focus on nearby sounds and
    filter out sounds further away show the most promise for addressing
    this problem. NIDCD-supported scientists have successfully completed a
    prototype of a low-power, highly directional microphone that is modeled
    on the acute directional hearing of a parasitic fly and is small enough
    to fit into a hearing aid. The device could offer hearing aid users
    significant improvement in their ability to listen to conversations
    amidst background noise. NIDCD's goal is for this research is to lead
    to the development of hearing aids that are more personalized and
    better able to restore normal hearing.
           identifying genes responsible for communication disorders
        NIDCD-supported scientists are identifying and describing genes
    involved in many communication disorders, including autism, dyslexia,
    stuttering, speech-sound disorders, and hearing loss. Currently,
    scientists have mapped more than 80 genes responsible for inherited
    hearing loss. Starting in fiscal year 2009, NIDCD is serving as the
    lead Institute for an NIH Government Performance and Results Act (GPRA)
    goal to ``identify or study additional genes involved in communication
    disorders in human and animal models by 2011.'' To achieve this goal,
    NIDCD- and other NIH-supported scientists are using the knowledge
    gained from the Human Genome Project to identify genes that play a role
    in communication disorders. These efforts will inform scientists as
    they develop genetic tests to predict communication disorders and
    personalize treatment plans for individuals affected by them. In a
    recent study, NIH-supported scientists scanned the human genome for
    genetic differences between individuals with and without autism. They
    identified both common and rare genetic factors that affect the risk
    for developing autism spectrum disorders (ASD). The results suggest
    that there are specific inherited genes that can cause abnormal
    connectivity between nerve cells in the brains of people with an ASD.
    These abnormal connections may be, in part, responsible for their
    communication difficulties.
                              autism and language
        According to the American Psychiatric Association, approximately
    20-40 percent of individuals with autism spectrum disorders have
    apparently normal intellectual abilities and relatively intact language
    skills, but they still have difficulty with the social aspects of
    communication. These individuals are categorized as having high-
    functioning ASD. In order to develop useful and appropriate treatment
    programs for them, scientists need to know what specific aspects of
    communication are most impacted. NIDCD-supported scientists have used
    standardized conversational tests to compare individuals with high-
    functioning ASD to age-matched individuals without ASD. These
    comparisons enabled them to identify three main areas of conversational
    difficulty for individuals with high-functioning ASD: (1) Managing
    topics--responding in a way that is pertinent to the topic and
    identifying topics of interest to both parties; (2) Managing
    information--understanding how much information is enough and knowing
    what type of information to provide; and (3) Establishing reciprocity--
    participating in a balanced back-and-forth exchange. Researchers can
    now use these results to develop personalized treatment programs
    targeted to improve existing conversational skills and build new skills
    in the areas of communication that are most affected in individuals
    with high-functioning ASD.
                            vocal fold regeneration
        The vocal folds--also referred to as vocal cords--are two elastic
    bands of tissue located in the larynx, or voice box, directly above the
    trachea, or windpipe. The vocal folds produce voice when air held in
    the lungs is released and passed through the partially closed vocal
    folds, causing them to vibrate. Vocal fold scars can result from injury
    or inflammation, or because of surgery to remove vocal fold nodules or
    polyps. The scars increase vocal fold stiffness and reduce their
    ability to vibrate. An individual with scarred vocal folds may have a
    hoarse, breathy, or low-pitched voice. NIDCD-supported scientists have
    developed a new class of soft gel material to serve as a scaffold to
    encourage regeneration of vocal fold tissue. Specific particles within
    the material can also be modified to bind and slowly release
    therapeutic drugs within the vocal folds as a way to further encourage
    regeneration of the tissue. This new material is currently being tested
    to learn what types of changes, such as particle size, distribution,
    and so on, will optimize tissue regeneration. Once the gel is optimized
    in laboratory tests, it may offer a potential future personalized
    treatment for individuals whose vocal folds have been damaged due to
    scarring.
        Mr. Chairman, I would like to thank you and members of this
    subcommittee for giving me the opportunity today to present examples of
    scientific advances made with the support of the NIDCD. I am pleased to
    try to answer your questions.
                                     ______

        Prepared Statement of Dr. Lawrence A. Tabak, Director, National
                 Institute of Dental and Craniofacial Research
        Mr. Chairman and members of the subcommittee: I am pleased to
    present the President's fiscal year 2010 budget request for the
    National Institute of Dental and Craniofacial Research (NIDCR) of the
    National Institutes of Health. The fiscal year 2010 budget includes
    $408,037,000 which is $5,385,000 more than the fiscal year 2009
    appropriation of $402,652,000.
                               facing the future
        Extraordinary advances have been made in recent years at the
    interface of traditional scientific disciplines. Multidisciplinary
    teams of scientists, engineers and clinicians have combined advances in
    biochemistry, cell and molecular biology, engineering, genetics, and
    neuroscience to gain a deeper understanding of the mechanisms
    underlying disease pathogenesis. This has yielded clues for the
    prediction of those most at risk for disease, approaches to
    personalized interventions, and strategies to prevent disease
    progression.
        For example, who has not marveled at the complexity of a face? Or
    how nature designed the mouth and its unique soft and hard tissues as a
    gateway to the body and, in some creatures, a first line of defense?
    Among Nature's greatest miracles of design and engineering is the
    craniofacial complex. Utilizing the many powerful research techniques
    and tools now available, teams of NIDCR-supported scientists are
    creating a publicly accessible informatics platform, termed FaceBase,
    that will enable multiscale analysis of all aspects of craniofacial
    development. This basic understanding is key to one day preventing and
    more effectively managing craniofacial defects and disorders. Each year
    thousands of infants are born with a variety of craniofacial
    dysmorphologies. While many of these conditions, such as cleft lip and/
    or palate can be managed surgically and with supportive therapies,
    others are more challenging to treat. For example, children born with
    ectodermal dysplasias must deal with either malformed or multiple
    missing teeth.
        The NIDCR's new strategic plan captures the communal spirit
    required to address complex oral and craniofacial diseases and
    conditions. It lays out the challenges of the immediate road ahead for
    dental, oral, and craniofacial research--challenges that our 2010
    budget positions us to meet. But above all, our plan lays out the great
    promise that awaits scientists and the American public in the years
    ahead.
                           widen the scope of inquiry
        As the volume of biological information has grown, so, too, have
    the questions that scientists can ask. No longer must the human body be
    neatly subdivided into its constituent parts and studied in strict
    isolation, one organ from another. Biological clues in one part of the
    body often have application elsewhere in the body.
        An excellent example is oral cancer which results in more than
    7,500 deaths each year in this Nation. Unlike cancers that arise in the
    internal organs, tumors of the oral cavity are often readily accessible
    for biopsy and prompt study. This has allowed a dedicated corps of
    scientists to make tremendous inroads into defining the molecular
    errors that trigger the disease. For example, a key signaling pathway,
    termed Akt-mTOR, is frequently dysregulated in head and neck
    carcinomas. Their research efforts not only will improve the diagnosis
    and treatment of oral cancer, it also will provide comparative data and
    possible new leads for scientists who study other less accessible
    tumors.
        The same is true of research on the microbial biofilm that forms on
    the hard and soft tissues of the mouth. Oral health researchers have
    defined more than 600 microbes that inhabit the mouth and have spent
    generations studying the communal dynamics that contributes to common
    diseases, such as periodontal disease and tooth decay. This decades-
    long head start will help to guide research now under way on the other
    biofilms that form throughout the body. This line of study emerges from
    the growing recognition that subtle shifts in the composition of the
    body's biofilms may play a major contributory role in myriad human
    diseases. Advances are being enabled by powerful new technologies that
    allow for the more facile sequencing and analysis of microbial genomes.
    Indeed, microbes that have not yet been cultivated are now amenable to
    study, in silico, which helps describe the lifestyle of each organism.
        NIDCR intends to make considerable investments in genome wide
    association studies of diseases and conditions affecting the
    craniofacial complex that will also inform pathology in other regions
    of the body. For example, an analysis of genes associated with
    Sjogren's syndrome, an autoimmune disease affecting 1 million or more
    Americans, will likely provide clues for other diseases such as
    rheumatoid arthritis or systemic lupus erythematosus. Chronic facial
    pain, including temporomandibular joint and muscle disorders, has begun
    to yield its secrets to the efforts of geneticists and neuroscientists.
    Particularly important are efforts to better understand the transition
    of acute to chronic pain. Compelling evidence suggests this may be
    related to neural plasticity, in a manner not dissimilar to mechanisms
    that underlie memory.
        These are but a few of the cross-cutting issues that are now on
    NIDCR's research agenda. To investigate them vigorously, the NIDCR must
    continue to encourage innovation and bring to bear the best science
    possible. But therein lays another challenge.
                            keep the pipeline strong
        For the Nation's oral health community to tackle NIDCR's ambitious
    research agenda successfully, it needs tight integration among
    research, practice, and education. This synergy holds the key to
    solving the many disorders that affect the oral and craniofacial
    complex. During 2010, the Institute will continue to emphasize training
    and career development for oral health professionals, to ensure that we
    increase a thriving community of dentist-scientists ready to capitalize
    on the rapid and significant advances occurring in biomedical and
    behavioral research. At the same time, the Institute must continue to
    attract scientists from outside its traditional research arenas. We
    will need to cover all of the scientific bases, from chemists and
    computer scientists to molecular biologists and mathematicians. All
    play critical roles and will be invaluable in ensuring that the best
    science moves rapidly into clinical studies. In an effort to strengthen
    the pipeline at every stage, the NIDCR is determined to maintain its
    high level of commitment in 2010 to funding new and early-stage
    investigators in a wide range of scientific fields.
                          promote clinical innovation
        Moving forward in the clinical realm will require a great deal of
    innovative thinking. In 2010, NIDCR will continue to lay the foundation
    for the next great revolution in oral healthcare: biology-based dental
    care. As the name suggests, dentistry will launch molecular-based
    healthcare over the next several decades. Using salivary-based
    diagnostics, this new oral health paradigm will provide patients with
    more precise diagnoses and a greater opportunity to practice
    prevention. Greater understanding of disease pathogenesis and the
    variation in individual susceptibility will yield targeted and
    personalized therapies to treat their conditions more efficiently. This
    will provide a better chance to maintain their teeth and supporting
    bone ultimately leading to a lifetime of high-quality health.
        To catalyze adoption of these advances, and to further the evidence
    base of the dental profession, in 2010, the NIDCR will continue to
    support its Practice Based Research Networks initiative, which now
    engages hundreds of dentists nationwide in scientific studies.
                           address health disparities
        As beneficial as biology-based dental care will be one day in
    improving the oral health of Americans, every effort must be made, now
    and in the future, to combat oral health disparities. Millions of
    primarily low-income Americans have yet to benefit fully from advances
    in dental care, including countless children and their families.
        The fiscal year 2010 budget request will allow the NIDCR to
    maintain strong support for its Centers for Research to Reduce Health
    Disparities. These Centers continue to demonstrate the value of
    partnering with communities throughout the research process in order to
    gain a complete understanding of the factors contributing to dental
    disease in each community and to develop appropriate intervention
    strategies. Emerging from this initiative will be a greater focus to
    identify the many complex factors that contribute to the disparities,
    targeted, multi-tiered research to address the problem, and coordinated
    efforts to promote greater awareness of oral disease.
        The Institute also plans to continue partnering with the Centers
    for Disease Control and Prevention to monitor the status of the
    Nation's oral health. As a part of this effort, the NIDCR will seek to
    validate new methods to measure and document oral, dental, and
    craniofacial diseases.
                           dental care in the future
        Biology-based dental care will transform the most fundamental
    principle of the profession: restoration of form and function. No
    longer will dentists rely as readily on mechanical instruments and
    ceramo-metallic materials to repair damaged tissue. They will
    regenerate form and function (a) using the precision of molecular
    information--or the underlying cause of the disease--as their
    operational guide and (b) employing the body's own cells and
    biochemistry as their engineering materials.
        Future dentists will possess more powerful optical instruments to
    visualize and accurately characterize whether near microscopic losses
    of mineral from a tooth surface will be self-correcting or whether they
    will progress to full blown decayed lesions. Advances in imaging,
    genomics and proteomics will allow a clinician to profile the circuitry
    of a tumor cell biopsied from the mouth. This diagnostic work-up will
    guide the choice of chemotherapy drugs to those that are most likely to
    target the internal wiring of the tumor cell and kill it. Targeted
    treatments will allow the removal of only the cancerous tissues.
        In closing, and as highlighted in our 2010 budget justification,
    the NIDCR will continue to invest in research and research training to
    meet emerging scientific opportunities and challenges. This budget
    request will enable us to work towards achieving the four goals
    outlined in our strategic plan. These goals are attainable, and in
    striving to meet them, we can realistically expect to improve the
    Nation's oral health for generations to come.
                                     ______

       Prepared Statement of Dr. Griffin P. Rodgers, Director, National
            Institute of Diabetes and Digestive and Kidney Diseases
        Mr. Chairman and members of the subommittee: I am pleased to
    present the President's fiscal year 2010 budget request for the
    National Institute of Diabetes and Digestive and Kidney Diseases
    (NIDDK) of the National Institutes of Health (NIH). The fiscal year
    2010 budget includes $1,781,494,000, which is $20,156,000 more than the
    fiscal year 2009 appropriation of $1,761,338,000. Complementing these
    funds is an additional $150,000,000 also available in fiscal year 2010
    from the special statutory Type I Diabetes Research Program for NIDDK.
        Our Institute supports research on a wide range of common, chronic,
    costly, and consequential health problems that affect millions of
    Americans. These include diabetes and other endocrine and metabolic
    diseases; digestive and liver diseases; kidney and urologic diseases;
    blood diseases; obesity; and nutrition research. Additionally,
    consistent with the President's commitment to increase funding for
    cancer research, and with the HHS-wide initiatives on autism, NIDDK
    will support research relevant to these diseases.
                      genetic factors in complex diseases
        Many complex diseases within the NIDDK mission result from
    interactions amongst multiple genetic and environmental factors.
    Building upon the wealth of genetic information from the Human Genome
    Project, basic research on genetic contributors to these diseases lays
    the foundation for translation of knowledge into clinical settings,
    where it can be used to better predict and pre-empt disease
    development, as well as provide more personalized medical care.
        For example, the NIDDK supported recent research uncovering six new
    genetic variants involved in type 2 diabetes. Combined with previous
    genetic findings, this new knowledge can help to determine who is at
    risk for this disease and how it might best be treated and prevented.
    NIDDK research has also recently shown how a genetic variant associated
    with type 1 diabetes works to alter immune function, enhancing
    understanding of this disease and highlighting potential targets for
    therapy. NIDDK also contributed to international research efforts
    yielding an explosion of new genes or gene regions associated with the
    inflammatory bowel disease known as Crohn's disease. The total number
    of known susceptibility genes currently stands at more than 30, each of
    which promises fresh insights into this disease and its management.
    Genetic analyses have also identified contributors to other diseases
    within the NIDDK mission, including nonalcoholic fatty liver disease,
    liver cancer, and diabetes-related kidney disease. Some of this
    research addresses populations disproportionately affected by certain
    diseases. For example, genetic variants were identified that account
    for much of the burden of nondiabetic kidney disease in African
    Americans. These studies may lead to future screening strategies and
    more personalized therapies.
        The NIDDK also participates in trans-NIH efforts exploring how
    genetic factors impact disease. Data from an NIDDK-sponsored study of
    the genetics of diabetic kidney disease are being analyzed by the Gene
    Association Information Network to inform disease prevention,
    diagnosis, and treatment. The NIDDK leads two projects within the
    Genes, Environment, and Health Initiative, which studies effects of
    genetic variants on disease risk in response to environmental
    exposures. The NIH Roadmap Epigenomics Program is researching how
    epigenetics--or biochemical changes to DNA--can control genes during
    different stages of development, such as fetal epigenetic responses in
    the intrauterine environment and the risk of diabetes after birth.
                     clinical and population-based research
        Clinical and population-based research generates important
    information not only for developing more effective therapies, but also
    for identifying strategies to pre-empt disease development--both
    essential for the future of medical care. NIDDK-sponsored research
    informs screening efforts to detect early signs of susceptibility and
    prevent full-blown disease. For example, recent studies have proven the
    potential of intensive early colonoscopy screening for precancerous
    polyps in African Americans to reduce their disproportionate colon
    cancer burden.
        NIDDK-sponsored efforts are also testing interventions to address
    type 2 diabetes related to overweight in both adults and children.
    Researchers are studying obese adults with type 2 diabetes to observe
    the effects of lifestyle changes to lower risk of diabetes
    complications. Similarly, in children, a study is determining if
    healthier food choices in schools, increased physical activity, and
    improved awareness of healthy behaviors can reduce weight and lower
    risk factors for type 2 diabetes--a disease that was once seen only in
    adults, but has been increasing in American youth.
        Obesity continues to be one of our Nation's most pressing health
    problems. The NIDDK supports a multi-pronged obesity research effort
    that includes studies of molecular and environmental contributors to
    feeding behavior and metabolism, processes such as inflammation in
    metabolic tissues, bariatric surgery and other potential treatments for
    obesity, and lifestyle interventions to prevent or reverse obesity. For
    example, a recent study showed that modest reductions in time spent by
    children watching TV or using the computer have beneficial effects on
    their weight.
        Clinical research is also yielding new insights into the
    development and management of kidney, urologic, and liver diseases.
    Recent clinical studies showed the limited effectiveness of drugs to
    enable vascular access during hemodialysis for kidney failure and for
    treating chronic kidney disease due to high blood pressure in African-
    American patients. A multi-center network is investigating causes of
    the two most common urologic pelvic pain disorders-interstitial
    cystitis/painful bladder syndrome and chronic prostatitis/chronic
    pelvic pain syndrome--which may yield new targets for managing these
    diseases. A new clinical research network conducting translational
    research on chronic hepatitis B is focused on understanding disease
    processes and applying this knowledge to more effective treatment and
    control strategies.
                        enhancing future health research
        The biomedical research enterprise will depend heavily on the next
    generation of investigators, innovative ideas of individual scientists,
    and the synergy of public-private partnerships. The NIDDK, along with
    the wider NIH, will continue its commitment to helping new
    investigators realize their potential through such efforts as special
    funding consideration, small grant and career awards, and mentoring
    workshops. The Institute also remains firmly committed to supporting
    investigator-initiated research. Public private partnerships through
    such entities as the foundation for the NIH will continue to expand the
    reach of NIDDK research.
        Strategic planning, analyses of disease burden, and research
    coordination are tools utilized by the NIDDK to advance research.
    Recently, the National Commission on Digestive Diseases--for which
    NIDDK provided leadership and support--released its long-range research
    plan, identifying challenges and opportunities for digestive diseases
    research. A separate report on the burden of digestive diseases in the
    United States was prepared by the NIDDK to inform this research plan.
    The ``NIDDK Prostate Research Strategic Plan,'' released in 2008,
    provides recommendations for future research efforts targeting the
    causes, prevention, and treatment of benign prostate disease.
        NIH recently initiated an effort to update its 2004 ``Strategic
    Plan for NIH Obesity Research'' in order to review research progress
    and identify new opportunities. This strategic planning effort is
    overseen by the NIH Obesity Research Task Force, which I co-chair
    together with Dr. Elizabeth Nabel, Director of the National Heart,
    Lung, and Blood Institute.
        Coordination to enhance research efforts across the NIH and with
    research partners in other Federal agencies is also achieved through
    the work of coordinating committees. The Diabetes Mellitus Interagency
    Coordinating Committee (DMICC) coordinates diabetes activities across
    the Federal Government and fosters opportunities for agency
    collaboration. In its coordinating role, the DMICC encourages Federal
    research collaborations, minimizes overlap of agency research efforts,
    and enhances public awareness of diabetes research and health
    information provided by Federal agencies. The DMICC is the focal point
    for diabetes research planning efforts.
                           promoting health awareness
        In addition to supporting health research, the NIDDK remains
    committed to ensuring that knowledge gained from research is used to
    promote health awareness. Relevant activities include the National
    Diabetes Education Program, National Kidney Disease Education Program,
    Weight-control Information Network, Celiac Disease Awareness Campaign,
    and programs to promote prevention of obesity and overweight.
        Recently, the NIDDK expanded its health information materials with
    a new Awareness and Prevention series of fact sheets. These
    publications are designed to raise awareness of diseases such as
    diabetes, digestive diseases, and kidney and urologic diseases among
    people not yet diagnosed with these illnesses. Materials produced by
    the NIDDK are often translated into multiple languages. For example,
    the Institute is currently developing Asian language materials on
    hepatitis B to reach people whose origins place them at higher risk--a
    priority highlighted at the NIH Consensus Development Conference on
    Management of Hepatitis B in October 2008.
        Another resource for promoting health awareness in affected groups
    is a set of teaching tools for school-based diabetes education in
    American Indians, who have the highest rates of diabetes in the United
    States. Through educating American Indian youth about diabetes
    prevention, these tools aim to reduce the incidence of type 2 diabetes
    in these young people and their families, as well as encourage entry
    into health-related careers.
                                closing remarks
        A key goal of the NIDDK is to maximize the return on research
    investments to derive the greatest health and economic benefits.
    Embedded in the population-based projects I mentioned is a
    consideration of their cost-effectiveness. As areas of research
    converge around common disease mechanisms--such as microbial influences
    on health--and research tools--like genetics-based technologies--
    opportunities exist to leverage resources and foster collaborations.
    Past investments in sample repositories and databases can be extended
    in ancillary and follow-up studies. In these ways, the intrinsic
    economic benefit of NIDDK-sponsored research can be fully realized.
        In closing, I thank the chairman and members of the subcommittee
    for this opportunity to highlight some of the NIDDK's research and
    outreach efforts to improve our Nation's health. I would be pleased to
    answer any questions you may have.
                                     ______

    Prepared Statement of Dr. Linda Birnbaum, Director, National Institute
                        of Environmental Health Sciences
        Mr. Chairman and members of the subcommittee: I am pleased to
    present the President's fiscal year 2010 budget request for the
    National Institute of Environmental Health Sciences (NIEHS) of the
    National Institutes of Health. The fiscal year 2010 budget includes
    $684,257,000, which is $21,437,000 more than the fiscal year 2009
    appropriation of $662,820,000.
                                  introduction
        NIEHS works at the forefront of public health to meet the
    challenges the field of environmental health sciences faces in the 21st
    century. Meeting these numerous and demanding challenges is vital to
    reducing and preventing disease burden across the Nation. As biological
    sciences generate a deeper understanding of the working of organisms at
    the molecular and systems levels, opportunities open to advance our
    knowledge of the effects of environmental exposures--not just the clear
    and obvious effects, but also the subtle, complex ways human health is
    affected by the environment. Tackling scientific questions with this
    level of complexity requires an ongoing evaluation of our ideas and
    approaches, and an emphasis on integration across disciplines--from
    computational and molecular, to clinical and public health, and
    everything in between. Our discoveries translate into improvements in
    environmental regulation, public health, and clinical practice.
        To improve our Nation's health, and to increase the benefits of our
    health care system, the use of medical interventions must go hand in
    hand with the adoption of behaviors aimed at disease prevention and
    wellness promotion. The goal of environmental health sciences is to
    remove human exposures to deleterious agents before disease processes
    and dysfunction begins. By advancing our understanding of the
    interactions of the environment with human health, and opening the door
    to new ways to prevent disease, NIEHS's investments serve to undergird
    a recovering economy and to support improvement of the health of our
    citizens, as well as our healthcare system. NIEHS budget request and
    research projects are also consistent with the President's multi-year
    commitment for cancer, autism, and nanotechnology.
                   neurological disorders and the environment
        There is continued concern that neurological disorders such as
    autism, attention deficit hyperactivity disorder (ADHD), and adult
    onset diseases such as Parkinson's and Alzheimer's may be rooted in
    early exposures to environmental toxicants. NIEHS supports basic
    research to determine the mechanisms and pathways by which toxicants
    may bring about neural damage to the developing brain. Some of the key
    neurotoxicants being studied are metals such as lead, mercury, and
    manganese; pesticides; tobacco smoke; and polychlorinated biphenyls and
    polybromated diphenyl ethers used to make insulating and fire retardant
    products.
        With NIEHS support, the Children's Center at the University of
    California, Davis is conducting the first large-scale human population
    study of children with autism. These researchers are looking at a wide
    range of environmental exposures and their effects on early development
    in more than 1,000 California children. NIEHS researchers are also
    developing new and improved animal and cellular models for ADHD and
    autism--models that will help determine how neurotoxic substances may
    impact brain development and behavior, and may be useful in testing
    therapies.
                environmental health and safety of nanomaterials
        Engineered nanoscale materials display novel physical, chemical,
    and biological properties that contribute to new technologies useful
    for drug delivery systems, tissue engineering, biological and
    environmental sensor technology, and environmental remediation. By
    2015, the global nanotechnology market is projected to exceed $15
    billion. Nanotechnology, like all emerging technologies, should create
    innovation while minimizing risk of adverse health effects, and health
    effects of exposure should be assessed prior to extensive use. Safety
    assessment is challenging due to the diversity of materials used to
    synthesize nanoparticles, as well as the wide range of physical and
    chemical properties that emerge at the nanoscale. NIEHS and the
    National Toxicology Program (NTP), which is headquartered at NIEHS,
    support research on the impact of size and size-dependent properties of
    nanomaterials on biological response at the systemic, cellular, and
    molecular levels. This research has begun to demonstrate trends in the
    relationship of physical and chemical properties to biological
    response. NIEHS and NTP will continue to support research that
    increases the understanding of potential health impacts of these novel
    materials, as well as help to guide development of nano-enabled
    products to reduce adverse health impacts in our increasingly exposed
    population.
                 environmental disruptors of endocrine systems
        Chemicals can mimic the hormones of our endocrine system and
    disrupt its functions, with potentially adverse effects on health and
    development. A consensus statement expressing concerns about the
    possible health effects of one such chemical, Bisphenol A (BPA), was
    issued by an expert panel as a result of a meeting organized by NIEHS
    in November 2006.
        NTP also recently completed an evaluation of BPA. BPA was selected
    for evaluation because of the volume produced, widespread human
    exposure, extensive animal data on reproductive and developmental
    effects, and growing public concern. BPA is used in plastic water
    bottles and containers, in some medical tubing, and in the plastic
    coating inside of food cans, among other uses. Data from the Centers
    for Disease Control and Prevention showed BPA in 93 percent of 2,517
    urine samples from people 6 years and older. The NTP evaluation graded
    various health concerns on a six-level scale: serious concern for
    adverse effects; concern; some concern; minimal concern; and negligible
    concern. NTP concluded there is ``some concern'' for effects on the
    development of the brain and behavior, and prostate gland development,
    in fetuses, infants, and children at current exposures, and ``minimal
    concern'' for effects on mammary gland and earlier age of female
    puberty in fetuses, infants and children at current levels of exposure.
    As a result of NTP's work, scientists at the Food and Drug
    Administration are reviewing their policies on BPA.
        In separate NIEHS-supported studies in rats, BPA exposure induced
    changes in the mammary gland that were time and dose specific, so that,
    for example, high-dose exposure resulted in architectural modifications
    in the number of undifferentiated epithelial structures of the breast
    tissue. High-dose exposures induced changes in genes related to cell
    differentiation suggesting alterations in the normal development of the
    gland. These studies are part of the larger NIEHS-National Cancer
    Institute program of Breast Cancer and Environmental Research Centers;
    NIEHS expects that these and other research findings will shed light on
    the ways in which environmental exposures can influence the risk of
    breast cancer in women.
                         hexavalent chromium and health
        Chromium compounds, such as hexavalent chromium, are widely used in
    electroplating, stainless steel production, leather tanning, textile
    manufacturing, and wood preservation. The United States is one of the
    world's leading producers of chromium compounds. Hexavalent chromium
    compounds have been shown to cause lung cancer in humans when inhaled,
    but it was not known whether these compounds could also cause cancer
    when ingested; hence they were nominated for NTP toxicity and
    carcinogenicity testing because of concerns over its presence in
    drinking water, its potential health effects, and the lack of adequate
    cancer studies on ingested hexavalent chromium.
        NTP studies showed that sodium dichromate dehydrate, a compound
    containing hexavalent chromium, causes cancer in laboratory animals
    following oral ingestion. Male and female rats developed malignant
    tumors in the oral cavity. In mice, the studies showed dose-related
    increases in the number of benign and malignant tumors in the small
    intestine. This is the first and only lifetime study that clearly
    demonstrates the carcinogenicity of hexavalent chromium in rodents
    after oral exposure.
        The results of these studies were closely monitored by many groups,
    including the affected industries and numerous national and
    international public health and regulatory agencies. The data will most
    certainly be used as the basis to develop State and Federal drinking
    water and soil cleanup standards, and will have significant public
    health impact on thousands of people exposed to hexavalent chromium in
    contaminated drinking water and soil.
                                   conclusion
        These examples highlight important NIEHS and NTP research on the
    environmental connection to human disease and stand in for other vital
    research supported by the Institute. Research, such as the Sister
    Study, an epidemiological study following a cohort of 50,000 sisters of
    women diagnosed with breast cancer, promises to produce ground breaking
    information on the environment's role in the causation of breast
    cancer.
        The field of environmental health sciences is beginning a new
    chapter of scientific progress, with new and better tools at our
    disposal, an expanding understanding of the human genome and its
    relationship with the environment, and young scientists coming into the
    field who are well-prepared and eager to apply these tools and
    knowledge to our current scientific challenges. I am honored, as
    Director of NIEHS and NTP, to facilitate the challenges and
    opportunities ahead to alleviate suffering and improve human health.
                                     ______

    Prepared Statement of Dr. Jeremy M. Berg, Director, National Institute
                          of General Medical Sciences
        Mr. Chairman and members of the subcommittee: I am pleased to
    present the fiscal year 2010 President's budget request for the
    National Institute of General Medical Sciences (NIGMS). The fiscal year
    2010 budget includes $2,023,677,000, which is $25,876,000 more than the
    fiscal year 2009 appropriation of $1,997,801,000.
        Each year, NIGMS-supported scientists uncover new knowledge about
    fundamental life processes. While answering basic research questions,
    these scientists expand our awareness and understanding of how disease
    takes hold in the body. Institute grantees also develop important new
    tools and techniques that have research and medical applications. The
    payoffs from NIGMS research investments are impressive on many fronts.
    As just one example, 67 scientists have received Nobel Prizes in
    recognition of the scientific breakthroughs they made with NIGMS
    support.
                        genetic studies guide treatments
        The future of medicine will center on precise diagnosis and
    personalized treatments. This is a departure from most of today's
    medical approaches, which are based on studies of populations and one-
    size-fits-all statistics derived from them. The ability to pre-
    emptively tailor healthcare to individuals offers huge potential for
    increasing the efficiency and effectiveness of efforts to preserve
    health over the course of a lifetime.
        Americans are eager for information that will help them make
    intelligent, individualized choices about their health. Toward this
    end, in 2000 NIGMS partnered with a number of other National Institues
    of Health (NIH) components in launching an effort to determine how
    genes affect the way people respond to medicines, including
    antidepressants, chemotherapy agents, and drugs for asthma and heart
    disease. Since then, studies by this Pharmacogenetics Research Network
    (PGRN) have shown that genetic information can help predict how beta-
    blockers, breast cancer medications, and nicotine patches will work in
    a specific person. In early 2009, PGRN researchers merged data sets
    from around the world to demonstrate that information about certain
    genetic variations could aid doctors in determining the proper,
    personalized dose of warfarin, a blood-thinning drug taken by millions
    of Americans. This work set the stage for a prospective clinical trial
    that will test if using such genomic information will make it quicker
    and easier to get the right dose and furthermore, whether doing so
    could prevent serious treatment complications like heart attacks,
    strokes, and internal bleeding.
        Other NIGMS-funded genetic studies have revealed surprising roles
    for RNA. Nobel laureates Andrew Fire and Craig Mello paved the way for
    this paradigm shift by showing that a process called RNA interference,
    or RNAi, silences the activity of targeted genes. RNAi is now being
    widely used both as a research tool and for the development of products
    that could combat diseases like cancer and HIV. In 2008, other NIGMS-
    supported scientists won the prestigious Lasker Award for their
    groundbreaking discovery of microRNAs, short RNA molecules that
    regulate gene function using some of the same mechanisms central to
    RNAi. Our rapidly expanding understanding of RNA's many roles is
    already providing novel medical insights, such as the linkage of
    abnormal microRNA levels to cancer and other diseases.
                    physical sciences shine light on biology
        The intersections between fields of science--such as those between
    the physical sciences of physics, chemistry, mathematics, and computer
    sciences and the biomedical and behavioral sciences--often yield
    particularly fruitful and high-impact lines of investigation. One
    timely example is the NIGMS-supported computational modeling tools
    being used to predict the spread of emerging infectious diseases and
    the results of possible interventions. These field-spanning approaches
    provide important insights to help policymakers and public health
    officials respond to outbreaks, including H1N1 flu.
        Further evidence of how basic physical science can greatly
    contribute to biomedical research is found in nuclear magnetic
    resonance (NMR). This technique, developed by physicists in the 1930s,
    underlies the well-known medical procedure of magnetic resonance
    imaging. But in the laboratory, NMR is the basis of some of the most
    powerful analytical methods in chemistry and biochemistry. In 2008,
    NIGMS-funded researchers used NMR to identify a contaminant in several
    batches of another widely used blood-thinning medicine, heparin. The
    scientists determined the chemical structure of the contaminant, which
    was only subtly different from heparin and therefore difficult to find
    by other methods, and showed how the contaminant could cause severe
    reactions and even death in humans. As a result of this work, NMR may
    now be used to screen additional drug preparations for contaminants
    that are difficult or impossible to detect by other means.
        A physics-based technique called X-ray crystallography is also key
    to understanding molecules that are central to health and disease.
    Using this approach along with NMR, scientists funded through a
    coordinated NIGMS effort called the Protein Structure Initiative (PSI),
    have produced a wealth of information about the shapes of proteins,
    which are essential to their functioning. Following successful pilot
    and production phases that included the development of critical tools
    and techniques, the Institute is now focusing the PSI on structures
    with specific biological roles and expanding its reach throughout the
    scientific community. This new direction, called PSI:Biology, will
    emphasize partnerships between biologists and high-throughput structure
    determination centers to address important biomedical problems and
    provide information that will aid the development of new medicines.
        Among the advances from chemistry studies are powerful imaging
    techniques that allow scientists to visualize life processes in
    unprecedented detail. The discovery and development of green
    fluorescent protein (GFP) is a case in point. GFP was first purified
    from jellyfish in 1962, and before long, NIGMS-funded American
    researchers were finding ways to use this new tool to monitor
    activities in living cells and organisms. These scientists, who won the
    2008 Nobel Prize in chemistry for their insights, put the GFP gene into
    a variety of organisms, including bacteria and worms. Today, GFP is an
    essential part of the fabric of biological research and is used, for
    example, as a key component of powerful drug development tools.
                         finding and funding innovation
        To keep knowledge streaming from the Nation's scientific
    laboratories, we must be agile in responding to the changing needs of
    researchers, both individuals and teams. The Institute has been a
    pioneer in novel funding programs that address the needs of the
    scientific community and encourage innovation. One good example is
    Konrad Hochedlinger, who received an NIH Director's New Innovator Award
    in 2007. This program, which NIGMS developed and administers, jump-
    starts the careers of unusually creative early stage investigators.
    Since groundbreaking work in 2007 in which other NIGMS-funded
    scientists reprogrammed ordinary skin cells to become induced
    pluripotent stem cells (iPS) this area of inquiry has exploded. Dr.
    Hochedlinger's project aims to unravel the many details of how
    reprogramming works. He is currently working on creating
    ``reprogrammable mice'' in which every cell can become an iPS cell
    capable of morphing into any cell type.
        Another New Innovator is explaining basic behavioral principles
    using animal models. Karin Pfennig is studying how different species of
    toads choose a mate, a decision that has costs and benefits and
    involves trade-offs. Understanding the fundamental drivers of such
    ``context-specific'' behavior may help us treat behavioral disorders in
    people and address behavioral aspects of disease transmission and
    spread.
        Dr. Pfennig has contributed to the research enterprise in another
    important way. As part of its commitment to training the next
    generation of scientists and increasing the diversity of the scientific
    workforce, NIGMS developed the Institutional Research and Academic
    Career Development Award (IRACDA). This program gives postdoctoral
    scientists mentored teaching experiences at minority-serving
    institutions. Through IRACDA, Dr. Pfennig pursued her own cutting-edge
    research at the University of North Carolina, Chapel Hill, while also
    teaching at a historically Black college, North Carolina Central
    University. Dr. Pfennig, who grew up in a single-parent household with
    very limited resources, attributes her desire to ``give back'' to her
    own great teachers and mentors who challenged her to pursue her
    ambition to become a scientist. Programs like IRACDA pay lasting
    dividends on many levels, providing role models for students, preparing
    future teachers, and promoting partnerships between institutions.
                    investing today for american prosperity
        In addition to building a solid foundation of knowledge for medical
    advances, basic biomedical and behavioral research yields tangible
    economic benefits. NIGMS grants support the salaries and laboratories
    of thousands of researchers throughout the United States. And NIGMS-
    funded advances have played a significant role in the development of
    the multi-billion-dollar biotechnology industry, which is now its own
    engine of discovery as well as a critical partner to the pharmaceutical
    industry.
        I want to close by affirming the Institute's deep appreciation for
    the extraordinary opportunities provided by the American Recovery and
    Reinvestment Act of 2009. In addition to its impact on stimulating the
    Nation's economy, this legislation will enable scientists to uncover
    new knowledge that will lead to better health for everyone. We intend
    to use these funds to support highly meritorious research that could
    not be funded with our regular appropriations and to further accelerate
    the tempo of science through targeted supplements to existing grants.
    NIGMS is also addressing research projects which are consistent with
    the President's multi-year commitment for cancer and autism. We are
    also eager to fund creative studies sparked by the new NIH Challenge
    and Grand Opportunities grant programs, which are designed to focus on
    health and science problems where significant progress can be expected
    in 2 years.
        Thank you, Mr. Chairman. I would be pleased to answer any questions
    that the subcommittee may have.
                                     ______

    Prepared Statement of Dr. Thomas R. Insel, Director, National Institute
                                of Mental Health
        Mr. Chairman, and members of the subcommittee: I am pleased to
    present the President's fiscal year 2010 budget request for the
    National Institute of Mental Health (NIMH) of the National Institutes
    of Health (NIH). The fiscal year 2010 budget includes $1,474,676,00,
    which is $24,185,000 more than the fiscal year 2009 appropriation of
    $1,450,491,000.
                     public health burden of mental illness
        According to the most recent estimates, roughly 12.5 million
    American adults reported mental illness symptoms so severe as to cause
    them significant disability in the past year.\1\ \2\ According to the
    World Health Organization, mental disorders are the leading cause of
    medical disability in the United States and Canada for people under age
    45. In contrast to many other chronic medical conditions, mental
    disorders typically begin at an early age, usually before the age of
    30. Indeed, mental disorders, such as schizophrenia, depression, and
    bipolar disorder, are increasingly recognized as the chronic medical
    illnesses of young people. These illnesses also shorten people's lives.
    Americans with serious mental illness die, on average, 25 years earlier
    than the general population.\3\
    ---------------------------------------------------------------------------
        \1\ Kessler RC, Chiu WT, Demler O, Walters EE. Prevalence,
    severity, and comorbidity of twelve-month DSM-IV disorders in the
    National Comorbidity Survey Replication (NCS-R). Archives of General
    Psychiatry, 2005 Jun;62(6):617-27.
        \2\ U.S. Census Bureau. Population Estimates by Demographic
    Characteristics. Table 2: Annual Estimates of the Population by
    Selected Age Groups and Sex for the United States: April 1, 2000 to
    July 1, 2004 (NC-EST2004-02) Source: Population Division, U.S. Census
    Bureau Release Date: June 9, 2005. http://www.census.gov/popest/
    national/asrh/
        \3\ Parks J, Svendsen D, Singer P, Foti ME (Eds.). Morbidity and
    mortality among people with serious mental illness. Alexandria, VA:
    Medical Director's Council, National Association of State Mental Health
    Directors (NASMHPD). October 2006. http://www.nasmhpd.org/
    general_files/publications/med_directors_pubs/
    Technical%20Report%20on%20Morbidity%20and%20 Mortaility%20-
    %20Final%2011-06.pdf
    ---------------------------------------------------------------------------
        The annual economic costs of mental illness in the United States
    are enormous. The direct costs of mental health treatment represent 6.2
    percent of all healthcare spending, \4\ which, according to the Centers
    for Medicare and Medicaid Services, totaled 15.8 percent of the gross
    domestic product in 2003. Indirect costs associated with mental
    illness, which include all nontreatment-related costs such as lost
    earnings, Social Security disability payments, homelessness, and
    incarceration, account for even greater expenses than the costs of
    direct mental healthcare. A recent study found that serious mental
    illnesses cost the United States at least $193 billion annually in lost
    earnings alone.\5\ A conservative estimate places the total direct and
    indirect annual costs of mental illness at well over $300 billion.\6\
    ---------------------------------------------------------------------------
        \4\ Mark TL, Levit KR, Coffey RM, McKusick DR, Harwood HJ, King EC,
    Bouchery E, Genuardi JS, Vandivort-Warren R, Buck JA, Ryan K. National
    Expenditures for Mental Health Services and Substance Abuse Treatment,
    1993-2003. SAMHSA Publication No. SMA 07-4227. Rockville, MD: Substance
    Abuse and Mental Health Services Administration, 2007. http://
    www.samhsa.gov/spendingestimates/SAMHSAFINAL9303.pdf.
        \5\ Kessler, RC, Heeringa S, Lakoma MD, Petukhova M, Rupp AE,
    Schoenbaum M, Wang PS, Zaslavsky AM. The individual-level and societal-
    level effects of mental disorders on earnings in the United States:
    Results from the National Comorbidity Survey Replication. Am J
    Psychiatry. 2008 Jun; 165(6):703-11.
        \6\ Insel TR. Assessing the economic cost of serious mental
    illness. Am J Psychiatry. 2008 Jun; 165(6):663-5.
    ---------------------------------------------------------------------------
                  mental disorders are chronic brain disorders
        NIMH's mission is to transform the understanding and treatment of
    mental illnesses through basic and clinical research, paving the way
    for prevention, recovery, and cure. These illnesses can now be studied
    as brain disorders, as they are becoming more accessible to medical
    science by using the tools of modern neuroscience. These disorders
    frequently begin in childhood and are chronic, affecting people of all
    races and ethnicities, in both rural and urban settings. To prevent a
    lifetime of disability for millions of Americans, NIMH research is
    directed toward identifying the biological basis of mental disorders,
    examining the psychological and social aspects that contribute to the
    disorders, and pinpointing targets for improved prevention, diagnosis,
    and treatment.
                        mental healthcare in the future
        In the future, the practice of medicine will be increasingly
    predictive, pre-emptive, personalized, and participatory. Genetics and
    clinical neuroscience will make this possible for mental illnesses.
    Clinical neuroscience seeks to discover fundamental knowledge about the
    brain and behavior and to use this knowledge to develop better tools
    for prevention, diagnosis, and treatment. For instance, biomarkers can
    detect risk to permit prevention, neuroimaging may facilitate
    diagnosis, and the discovery of new molecular targets should yield
    novel treatments. The study of pathophysiology is fundamental for
    NIMH's mission, which is to use science to transform care: not merely
    to reduce symptoms among persons with mental illness, but to promote
    recovery among this population and ultimately to discover pre-emptive
    interventions that can prevent psychosis, disability, and suicide.
        In pursuit of this mission, NIMH is in the process of implementing
    its new Strategic Plan, which details the scientific priorities that
    will direct and accelerate mental health research in the years to come.
    The American Recovery and Reinvestment Act of 2009 (the Recovery Act)
    directs part of the Nation's stimulus funding to support job creation
    and retention in the field of biomedical research. These supplemental
    funds present an exciting opportunity for NIMH, allowing us to
    jumpstart the groundbreaking science outlined in the Strategic Plan, as
    well as the strategic plans of the NIH Office of AIDS Research and the
    Interagency Autism Coordinating Committee (IACC). This commitment will
    expand our knowledge about the underlying biology of mental disorders
    and accelerate the development of improved diagnostic measures and
    treatments. The fiscal year 2010 budget continues support for the IACC.
    NIH will receive $1 million from the Office of the Secretary to support
    the Committee.
        Mental healthcare in the future will be based on the ability to
    predict those most at risk, prevent the onset of disorder, and, in
    cases where prevention is not possible, develop treatments tailored to
    the individual. This requires collaboration among the diversity of
    people affected, including mental healthcare providers, researchers,
    and people with mental illness and their families. An example of NIMH
    research taking this approach is our recent partnership with the U.S.
    Army to reduce suicide among soldiers. The high rates of mental health
    and behavioral adjustment problems among recent U.S. military combat
    veterans and the increasing rates of suicide among Army soldiers are of
    growing concern. To address this issue, NIMH and the U.S. Army are
    collaborating on a $50 million research project, which will be the
    largest single study NIMH has undertaken on the subject of suicide. The
    project seeks to strengthen the Army's efforts to reduce suicide among
    soldiers by identifying the risk and protective factors associated with
    suicidal thinking and behavior. While targeted for the Army, the
    study's findings will also inform our understanding of suicide in the
    other Armed Forces as well as the overall population, leading to more
    effective prevention and treatment for servicemembers and civilians
    alike.
        While we have long known that mental disorders are brain disorders,
    recent research has begun to reconceptualize these illnesses as
    disorders of brain development. Between infancy and adulthood dramatic
    changes are taking place in the brain, not only in size, but also in
    structure and function. Understanding these changes and how these
    trajectories can go off course provides unprecedented promise for the
    prediction and prevention of mental disorders, as well as opportunities
    to harness this knowledge to improve treatments for individuals who go
    on to develop a disorder, either in childhood or in early adulthood. As
    an example, research on brain development in children with attention-
    deficit/hyperactivity disorder (ADHD) from the NIMH Intramural program
    recently reported a striking delay in cortical maturation. Between ages
    5 and 15, the maturation of the prefrontal cortex was found to be
    delayed by roughly 3 years in children with ADHD compared to age-
    matched children without the disorder. Current studies are now
    exploring the effects of treatment on the rate of cortical maturation.
        The prototype neurodevelopmental disorder for NIMH is autism.
    Matching the increasing public health urgency of autism, NIMH research
    over the past year has yielded important discoveries on the
    pathophysiology of autism spectrum disorders (ASD). Research has shown
    that different cases of ASD could potentially be traceable to any of 50
    or more variations in the genome, alone or in combination, suggesting
    that ASD may be the final common path for many different genetic
    abnormalities. Most of the genes implicated are critical for brain
    development. For example, independent teams of researchers have linked
    inherited variations in a gene on Chromosome 7, called CNTNAP2, with
    ASD. CNTNAP2 is part of a family of genes that make proteins that play
    a key role in building the machinery by which brain cells communicate.
    One variation of this gene was found to influence the age at which
    children with ASD say their first word. Another variation was
    identified that increases the risk for ASD, but mainly when it is
    inherited from mothers. These studies provide evidence that CNTNAP2,
    when disrupted, may represent one path to the development of ASD. In
    addition to breakthroughs in the genetics of autism, recent research
    has provided new tools for diagnosing autism as early as the first
    birthday. Early diagnosis is critical because early intervention is
    associated with the best outcomes.
        In order to build upon these research advances, NIMH will be using
    Recovery Act funding as an opportunity to fuel further research on ASD,
    including its underlying biology, methods for earlier and more
    effective diagnosis, and improvements in treatment. The new IACC
    Strategic Plan for ASD Research provides the scientific goals and
    benchmarks for this endeavor (www.iacc.hhs.gov). NIMH, in collaboration
    with other NIH Institutes, has issued a series of funding opportunity
    announcements (FOA) to address the heterogeneity of ASD. This will be
    the largest single funding opportunity for ASD research in NIH's
    history. NIMH may contribute as much as $30 million of the total $60
    million of Recovery Act funds that NIH has set aside for this effort
    (actual expenditures will depend on the proposals received). These FOAs
    encourage applications for 2-year projects that address ASD
    measurement, identification of biomarkers and biological signatures,
    immune and central nervous systems interactions, genetics/genomics,
    environmental risk factors, and ASD intervention and treatment.
    Additionally, we will be supporting autism research with Recovery Act
    funding through NIH's new Challenge Grants in Health and Science
    Program. This program encourages applications on a diverse range of
    research topics, such as improving access to services by individuals
    with ASD and their families and expanding NIH's National Database for
    Autism Research in order to accelerate the availability of new data for
    the ASD research community. Finally, NIMH intends to continue to build
    its investment in autism research via its base budget, which supports a
    new intramural program for autism research, Autism Centers of
    Excellence, and a broad range of individual grants for research and
    training related to ASD.
        Understanding the pathophysiology underlying mental disorders will
    not only lead to the improved prevention, diagnosis, and treatment of
    the disorders themselves, but will also help to clarify the
    relationships that exist between mental disorders and other physical
    health problems, such as cancer. People with mental disorders smoke
    cigarettes at twice the rate of those without such a disorder, and they
    consume 44 percent of all cigarettes smoked in the United States.\7\
    NIMH research is not only addressing this major public health problem
    through behavioral studies on smoking cessation techniques in these
    populations, but is also seeking to understand the underlying causes of
    smoking behavior. Several studies are examining the link between
    cognitive function, which is often disrupted in severe mental illness,
    and its improvement through nicotine use. By gaining better insight
    into how nicotine influences neural mechanisms, NIMH researchers are
    hoping to discover new ways of improving cognitive function among
    people with mental illness, ultimately reducing the severe health
    consequences associated with tobacco use.
    ---------------------------------------------------------------------------
        \7\ Ziedonis D., et al. Tobacco Use and Cessation in Psychiatric
    Disorders: National Institute of Mental Health Report. Nicotine Tob
    Res, 2008;10: 1-25.
    ---------------------------------------------------------------------------
        In summary, we are well positioned to fulfill the promise of
    predictive, pre-emptive, personalized, and participatory medicine in
    the future. By using the best tools, funding the best science,
    listening to our partners, and engaging our communities, we continue to
    make progress toward our goal of transforming the understanding and
    treatment of mental illnesses through basic and clinical research,
    paving the way for prevention, recovery, and cure.
                                     ______

    Prepared Statement of Dr. Story C. Landis, Director, National Institute
                      of Neurological Disorders and Stroke
        Mr. Chairman and members of the subcommittee: I am pleased to
    present the President's fiscal year 2010 budget request for the
    National Institute of Neurological Disorders and Stroke (NINDS) of the
    National Institutes of Health (NIH). The fiscal year 2010 budget
    includes $1,612,745,000, which is $19,401,000 more than the fiscal year
    2009 appropriation of $1,593,344,000.
        The important and challenging mission of NINDS is to reduce the
    burden of neurological disorders through research. Hundreds of
    disorders of the brain, spinal cord, and the nerves of the body affect
    people of all ages. Collectively, they cause an enormous burden in lost
    life, disability, and suffering, and cost billions of dollars each year
    in medical expenses and reduced productivity. The causes of nervous
    system disorders are diverse; among them are physical forces of
    traumatic brain injury, slow degeneration of nerve cells in Parkinson's
    and Alzheimer's disease, gene mutations in brain tumors and inherited
    diseases, blood vessel block or bleeding in stroke, and toxic effects
    of treatments for cancer, HIV/AIDS, and other diseases. Compounding the
    challenge, the brain and spinal cord are intricate in structure,
    difficult to access, sensitive to intervention, and do not readily
    repair themselves following damage.
                            planning for the future
        Over the last 2 years, NINDS has engaged the scientific community
    and the public in strategic planning to meet these challenges. Planning
    took a ``blue sky'' look at the future, but also gave outside experts
    unprecedented access to data about NINDS programs to inform
    recommendations of practical steps to better carry out our mission.
    Even as we finalize the strategic plan and seek further public input,
    we are implementing recommendations. One major lesson from planning is
    the importance of program evaluation; based on the results we are
    reallocating resources to maximize public health impact. Perhaps the
    most important message for today, however, is not at the level of
    program details, but about where we stand with respect to the NINDS
    mission-treatments for neurological disorders are still far from
    adequate, but research is yielding remarkable progress, and the
    prospects for the future are very encouraging.
        NINDS's budget request and its research projects are consistent
    with the President's multi-year commitment for cancer and autism.
                                     stroke
        Stroke, the ``S'' in NINDS, shows how far we have come and how far
    we have to go. Stroke remains the third leading cause of death in the
    United States and a major cause of long-term disability. However,
    American Heart Association statistics show that the age-adjusted stroke
    death rate decreased by 29.7 percent from 1995 to 2005, and actual
    stroke deaths declined by 13.5 percent, resulting in thousands of lives
    saved. Many NIH research studies contributed to the decline by
    predicting who is at risk for stroke, who will do best on which drug,
    and whether surgery to clean a carotid artery or repair an aneurysm is
    worth the risk for a particular patient. Research on stroke prevention
    is continuing apace, including research on the geographic and racial
    disparities.
        About a decade ago, a NINDS clinical trial demonstrated that
    appropriate use of the clot buster tPA can restore blood flow to the
    brain and significantly improve outcome from stroke. New clinical
    trials are building on this first successful emergency treatment by
    testing whether ultrasound improves tPA's effectiveness to break up
    clots in large brain arteries and whether direct injection of tPA into
    a blocked brain artery or clot retrieval devices may help some
    patients. Despite its proven benefit, too few people now receive tPA,
    which must be administered after specialist assessment and within a few
    hours of a stroke. A trial this year showed that telemedicine can
    expand access to emergency stroke treatment to areas of the country
    without specialized stroke centers. A second trial is assessing whether
    emergency personnel in the field can rapidly deliver a therapy to
    protect the brain prior to reaching a hospital. Beyond prevention and
    emergency treatment, a major challenge for stroke, as for traumatic
    brain injury, is promoting recovery after brain damage has occurred.
    Rehabilitation that harnesses the brain's ``plasticity'' is showing
    promise in people, and trials are assessing the most effective
    strategies, but there is still a long way to go.
                            genes and brain diseases
        Although there are hundreds of neurological disorders, common
    themes unify research across diseases. One lesson of planning is the
    importance of engaging the insight and ingenuity of researchers
    throughout the United States to recognize shared disease mechanisms and
    common therapeutic strategies. Research on genes is one unifying theme
    that spans many areas of basic and clinical science.
        A first wave of progress identified single gene defects that cause
    more than 200 neurological disorders, and continues with new findings
    in inherited types of ALS and other diseases. Often, the most immediate
    benefit of gene findings is genetic tests, which can spare families
    expensive and frustrating diagnostic odysseys to find out what is wrong
    with their child. Even when a single gene defect is identified, major
    obstacles confront therapy to correct the defect, especially in the
    brain, but there is progress; this year, for example, a preliminary
    clinical trial established the feasibility of gene transfer to treat
    Batten disease. Genes can also provide the first foothold on
    understanding causes and developing drug treatments, leading to
    rational therapy development programs, as NINDS has underway for
    muscular dystrophy, spinal muscular atrophy, and other disorders.
    Although most brain tumors are not inherited, acquired gene defects
    drive tumor formation. Observing which genes are affected in
    glioblastoma and other brain tumors is suggesting which tumors respond
    to which cancer drugs and providing clues to developing more effective
    treatment.
        Recently, scientists have begun to crack the more complex ways that
    variations in multiple genes together contribute to common neurological
    disorders and shape individual differences in therapy response. Gene
    tests show promise for establishing the appropriate dose of the drug
    warfarin, which is commonly used to prevent stroke in people with
    certain risk factors. Warfarin now requires frequent blood tests to
    find the safe and effective dose because of variability among people,
    and people are at risk until the dose is set. Genome-Wide Association
    Studies (GWAS) are one method that has associated genes with multiple
    sclerosis, Parkinson's disease, stroke, and other common disorders. For
    example, understanding autism is an NIH-wide priority, and
        GWAS recently implicated molecules that have been studied in the
    development of connections among nerve cells, linking a dynamic area of
    basic research to this disease.
                  translating scientific insights to therapies
        NINDS basic and clinical research yield understanding of disease
    and clinical tools that are essential for therapy development in the
    private sector. The Institute has also long pursued translational
    opportunities that are not likely to be targeted by others, whether
    because bold therapeutic strategies present uncertainty and long
    development horizons that are not tolerable to investors, rare diseases
    represent a small market, or developments in surgery and interventions
    using existing drugs may not recapture investments. The NINDS
    Intramural program developed the first successful enzyme therapy for
    inherited disease. Among applied NINDS extramural programs, the
    Anticonvulsant Screening Program has catalyzed the development of
    several epilepsy drugs now on the market, and the Neural Prosthesis
    Program successfully pioneered devices to restore lost nervous system
    functions. In 2003, NINDS moved from selective translational research
    in a few areas, to a broad effort to capitalize on opportunities across
    all neurological disorders by initiating the Cooperative Program in
    Translational Research. This program supports academic and small
    business investigator-initiated preclinical therapy development, using
    milestone driven funding and peer review expertise and criteria
    tailored to therapy development. Therapies from this program have
    received investigational approval from the FDA and are moving to
    clinical trials. Based on the advice of strategic planning advisory
    panels, which included industry experts, NINDS has created an Office of
    Translational Research and recruited a leader who has extensive drug
    development expertise. The new office will coordinate and focus NINDS
    applied programs more effectively on therapy development, without
    reducing NINDS commitment to basic and clinical research that is the
    foundation for progress. As new opportunities for therapy development
    emerge, we cannot let them languish in the ``valley of death'' between
    the idea and the success.
        Progress against two gene disorders that cause nervous system
    tumors illustrates how basic understanding of disease can drive
    research toward treatment. In people who have neurofibromatosis type 1,
    tumors grow within nerves and can cause disabling symptoms by
    compressing nerve, spinal cord, and other organs. Several years ago
    NIH-funded investigators discovered gene mutations that cause the
    disease and developed animal models that mimic the human disorder.
    After years of work, researchers discovered how the mutant gene causes
    cells associated with nerves to develop tumors, and then recruit other
    cell types and blood vessels to the tumor. Once researchers understood
    the molecular steps, they recognized that the cancer drug Gleevec acts
    on the same molecules. They are now testing the drug in people who have
    neurofibromatosis.
        Tuberous sclerosis complex is another disorder in which tumors,
    called tubers, can grow in nearly any tissue, including the brain. Many
    people with this disease also develop epilepsy or autism. Again,
    finding genes led to understanding of the molecular steps in disease,
    and scientists recognized that an available drug, rapamycin, which is
    used to prevent organ transplant rejection, affects a key molecule in
    the disease process. Studies in mice that mimic the human disorder were
    especially encouraging because the results suggest that the disease can
    be reversed in adults, countering pessimism that the disease produced
    irreversible affects on brain development. Researchers are exploring
    whether rapamycin or similar drugs are safe for long-term use, and may
    also be of benefit for epilepsy or autism from other causes.
                             the research workforce
        As science progresses, we recognize themes that bring together
    research on disparate diseases, whether shared disease mechanisms, as
    in neurodegeneration, therapeutic approaches, as stem cells, or program
    needs, as translational research. The American Recovery and
    Reinvestment Act reminds us of another common theme--research is labor
    intensive. Progress depends on the men and women who do research and
    their commitment to research that may take decades. To maintain the
    vigor of NIH and private research, NINDS is committed to making
    research an attractive and sustainable career for young people who are
    innovative, intelligent, dedicated, and diverse.
                                     ______

        Prepared Statement of Dr. Patricia A. Grady, Director, National
                         Institute of Nursing Research
        Mr. Chairman and members of the subcommittee: I am pleased to
    present the President's fiscal year 2010 budget request for the
    National Institute of Nursing Research (NINR) of the National
    Institutes of Health (NIH). The fiscal year 2010 budget request
    includes $143,749,000, which is $1,870,000 more than the fiscal year
    2009 appropriation of $141,879,000.
        NINR's budget request and its research projects are consistent with
    the President's multi-year commitment for cancer and autism.
                                  introduction
        NINR supports clinical and basic research to build the scientific
    foundation for clinical practice, prevent disease and disability,
    manage and eliminate symptoms caused by illness, and enhance end-of-
    life and palliative care. The breadth and depth of NINR's research
    portfolio is ideally suited to explore some of the most important
    challenges affecting the health of the American people. An aging
    population, an increasing incidence of chronic illness, a shortage in
    the health workforce, and rapidly escalating costs necessitate profound
    changes in the ways in which we approach healthcare. These challenges
    require us to develop new strategies for treating, managing, and
    preventing illness that are person-centered rather than disease-
    centered, that focus on pre-empting the development of chronic illness
    rather than treating it, and that feature the person as an active
    participant in managing his or her own healthcare. The research
    supported by NINR can significantly contribute to the evidence base for
    many of the changes that will occur in healthcare in the coming years
    and decades. NINR advances science to address current and future
    challenges through its research programs in health promotion and
    disease prevention; self-management, symptom management, and
    caregiving; and end-of-life and palliative care. In addition, NINR
    maintains a strong commitment to the elimination of health disparities
    faced by at-risk and underserved populations through continued work to
    develop culturally appropriate, evidence-based interventions. NINR also
    trains the next generation of scientists to ensure the development of
    the innovative research and faculty workforce of the future. The
    research goals in NINR's strategic plan, changing practice, changing
    lives, emphasize the areas of public health that demonstrate the
    greatest needs and in which NINR can have the greatest impact.
        Let me now describe our research programs and highlight some of our
    recent accomplishments.
                             ninr research programs
    Health Promotion and Disease Prevention
        Healthcare professionals and policy leaders have stressed the
    importance of preventive care to the health of all Americans. NINR
    supports research to discover new ways to prevent disease and achieve
    long-term, positive health outcomes in individuals across the lifespan.
    NINR-supported scientists explore strategies to understand and promote
    behavioral changes in individuals, evaluate health risks in diverse
    communities, and assess issues of patient safety. In recent years,
    successful efforts in the areas of health promotion and disease
    prevention research have increasingly involved community members in the
    design and conduct of the study.
        NINR research has an impact on clinical practice. In one example,
    researchers designed, implemented and evaluated a program to address
    the health burden and costs associated with premature birth, a
    condition affecting more than 500,000 infants in the United States
    every year. The Creating Opportunities for Parent Empowerment program
    (COPE), for parents of premature infants, is an educational-behavioral
    intervention program that begins 2 to 4 days after admission to a
    neonatal intensive care unit (NICU) and teaches parents how to care for
    their premature infant. The researchers found that COPE implementation
    reduced the length of stay in the NICU by 4 days, for an estimated
    healthcare cost savings of at least $4,800 per infant. Thus, in
    addition to improving parent and child outcomes, routine implementation
    of COPE in NICU's across the United States could possibly save the
    healthcare system more than $2 billion per year. The results of this
    study have sparked interest among hospitals and insurers nationwide.
        NINR-supported researchers are developing more programs to promote
    healthy behaviors and prevent disease, including: an outreach
    intervention designed to reduce HIV-risk among adolescent girls
    receiving services through community-based health centers; a parent
    training program designed to promote positive parenting and mental
    health among low-income ethnic minority families with young children;
    and a lifestyle-modification program for prehypertensive, middle-aged
    rural women.
              self-management, symptom management, and caregiving
        Given the increasing numbers of people living with chronic illness,
    whether children with diabetes or elders with heart disease, NINR is
    developing new approaches to help individuals manage their own health
    conditions, to decrease the effects of adverse symptoms, and to reduce
    the burden on caregivers. NINR is improving the quality of life of
    individuals with chronic illness and their families by supporting
    research related to self-management, symptom management, and
    caregiving.
        Our self-management research explores strategies that help
    individuals to participate in their own health practices. In one recent
    example, community ``Lay Health Educators'' were trained to deliver a
    health promotion and asthma management program to children in
    elementary schools from rural towns and unincorporated communities.
    Children receiving this program demonstrated significant improvements
    in asthma knowledge, self-management scores, and use of metered dose
    inhalers. Results from this study suggest that using Lay Health
    Educators for delivery of an in-school education program may be an
    effective means for improving children's skills in asthma self-
    management, especially in hard-to-reach communities.
        Our symptom management research focuses on the biological and
    behavioral aspects of symptoms such as pain and fatigue, with the goal
    of improving patient health and quality of life. A recent symptom
    management study aimed to define patient-determined success for
    treatment of chronic spine pain in four areas: pain, fatigue, emotional
    distress, and interference with daily activities. This study found that
    the patients for whom pain was reduced experienced significantly less
    fatigue, emotional distress, and interference with daily activities.
    The findings confirm that successful treatment for chronic pain is not
    viewed by patients exclusively in terms of pain reduction, but also
    involves a number of additional quality of life factors.
    Research Capacity Development
        The increasing demand for nurse clinicians, faculty, and
    scientists, and the inadequate supply of new nurses to meet that need,
    continue to burden America's health system. NINR builds research
    capacity and fosters interdisciplinary training for the next generation
    of scientists in basic, translational, and clinical research through
    individual and institutional training and career development awards.
    NINR training strategies focus on the development of nurse scientists
    and earlier entry into research careers with special consideration
    given to underrepresented and disadvantaged populations. In addition,
    innovative training programs at the NIH, such as the NINR Summer
    Genetics Institute, the NINR Graduate Partnerships Program, and the new
    BNC fellowship (a joint venture between NINR, the NIH Clinical Center,
    and the Bravewell Collaborative), all serve to increase the knowledge
    and experience base of new scientists, and assist them in their
    transition to long-term research careers.
    End-of-life
        Faced with a complexity of life-limiting and eventual terminal
    conditions--whether cancer, heart disease, stroke, or neurodegenerative
    disorders--the challenges experienced by patients and their families as
    life draws to a close have refocused attention to the end of life and
    necessitated a better understanding of the dying process, the
    associated decisions about treatment, and the quality of care patients
    receive. Focusing on these topics, NINR end-of-life research seeks
    through science to improve the understanding of the mechanisms
    underlying palliation, including pain, fatigue, depression, and related
    symptoms; enhances communication and decision-making processes between
    patients and family members; and develops effective strategies to
    optimize care across diverse settings, populations, and cultural
    contexts.
        One recent study explored the relationship between diagnosis and
    advance directives. As part of a longitudinal study, patients with an
    expected 2-year survival of less than 50 percent who had either cancer
    or amyotrophic lateral sclerosis (ALS) were interviewed with the goal
    of determining whether and how end-of-life discussions differed between
    clinicians and patients. Results showed that cancer patients were less
    likely than ALS patients to have had advanced care planning
    discussions. Although these results may reflect perceptions that ALS
    has a more predictable disease trajectory, that advanced cancer has a
    greater number of treatment options, or the presence of differing views
    about hope, this study highlighted that cancer patients may be less
    than adequately prepared for end-of-life decisionmaking.
        Another recent study examined the life support withdrawal process
    for patients who died in the intensive care unit (ICU) or within 24
    hours of discharge from the ICU, and surveyed family members on their
    perceptions of the care provided. The researchers discovered that for
    family members of patients who had an ICU stay of 8 days or more,
    families were more satisfied with care received when withdrawal of life
    support occurred in a staggered progression. The outcome of this study
    indicates that clinicians need to work with the family throughout the
    patient's ICU stay to provide them with accurate information on which
    to base decisions, and prepare them emotionally for the possible loss
    of their loved one.
              ninr and the american recovery and reinvestment act
        Funding for scientific research received through the American
    Recovery and Reinvestment Act of 2009 (ARRA) has provided NINR with an
    enormous opportunity, not only to assist with the Nation's economic
    recovery by creating and retaining jobs and enhancing infrastructure,
    but to advance biomedical and behavioral research in areas of critical
    importance to the NINR mission. NINR is using the funds from ARRA to
    support additional research projects, to accelerate ongoing research
    through supplements to current grants, and to create opportunities for
    introducing prospective scientists to a research career. The additional
    science supported by NINR through ARRA will, in the long-term,
    contribute to improving the health of the Nation through enhanced
    prevention and management of chronic illness and disease.
        Thank you, Mr. Chairman. I will be happy to answer any questions
    that the subcommittee might have.
                                     ______

      Prepared Statement of Dr. Donald A.B. Lindberg, Director, National
                              Library of Medicine
        Mr. Chairman and members of the subcommittee: I am pleased to
    present the President's fiscal year 2010 budget request for the
    National Library of Medicine (NLM) of the National Institutes of Health
    (NIH). The fiscal year 2010 budget includes $334,347,000, which is
    $3,576,000 more than the comparable fiscal year 2009 appropriation of
    $330,771,000.
        NLM, the world's largest biomedical library and the developer of
    electronic information services, delivers trillions of bytes of data to
    millions of users daily. Every day 3.5 terabytes of data are downloaded
    to users. By making research results--from DNA sequences to clinical
    trials data to published scientific articles and consumer health
    information--readily available, the Library magnifies the positive
    impact of the NIH's investment in the creation of new knowledge. By
    organizing increasing amounts and types of biomedical and health
    information, the NLM fuels new research discoveries, informs patient
    care decisions, helps people exert control over their health and
    healthcare, and AIDS disaster preparedness and response.
        The NLM is a key enabler for important congressional, NIH, and
    Department of Health and Human Services (HHS) initiatives. NLM's budget
    request and its research projects are consistent with the President's
    multi-year commitment for cancer and autism. Current priorities
    include: increasing the transparency of clinical trials in
    ClinicalTrials.gov; enhancing public access to NIH-funded peer-reviewed
    manuscripts in the PubMed Central archive; making results of Genome-
    Wide Association Studies (GWAS) available in dbGaP to improve the
    understanding of genetic and environmental factors underlying human
    disease; supporting and distributing standard terminologies for
    electronic health records and clinical research data, including genetic
    tests, within NLM's Unified Medical Language System; conducting
    biomedical informatics research on health applications of information
    technology; and developing specialized information resources for use in
    emergency and disaster response.
        To be useful, NLM's information services must be known and readily
    accessible. The Library's outreach program relies heavily on the 5,800-
    member National Network of Libraries of Medicine (NN/LM) and on
    exhibitions, events, and varied media to bring the message about NLM's
    free, high-quality health information resources to communities across
    the Nation. The NN/LM comprises academic health sciences libraries,
    hospital libraries, public libraries, and community-based
    organizations. They form an efficient way to make the published output
    of biomedicine easily accessible by scientists, health professionals,
    and the public and to develop partnerships with community organizations
    and underserved populations.
                        scientific information resources
        The NLM's National Center for Biotechnology Information (NCBI)
    meets the challenge of collecting, organizing, storing, analyzing, and
    disseminating scientific data by designing, developing, and
    distributing the tools, databases and technologies that are enabling
    the genetic discoveries of the 21st century. Celebrating 20 years since
    its enactment, the Center is at the hub of international interchange of
    molecular biology and genomic information, with Web sites accessed
    several million times a day.
        In addition to the widely known GenBank and PubMed/MEDLINE
    databases, the NCBI provides a wide array of genomic resources and is a
    valued collaborator throughout the NIH. The recent discovery of a novel
    H1N1 influenza virus highlights the value of the specialized virus
    resource that NCBI developed with the National Institute of Allergy and
    Infectious Diseases. It links vaccine researchers to genomic data about
    the influenza virus. The PubChem repository fills a critical need in
    the Molecular Libraries Roadmap Initiative, with information on more
    than 40 million ``small molecules'' that are crucial in drug
    development. The dbGaP database, which links genotype data with
    phenotype information from clinical research studies to support
    identification of genetic factors that influence health, is the public
    repository for the trans-NIH GWAS project. NIH's mandatory Public
    Access Policy ensures scientific articles written by NIH-funded authors
    are deposited in PubMed Central and linked to other scientific
    information.
        The Lister Hill National Center for Biomedical Communications leads
    research to create and improve biomedical communications systems,
    technologies, and networks. The Center recently completed a major
    expansion of ClinicalTrials.gov, in response to the congressional
    mandate. The system now maintains a registry of clinical trials
    involving FDA-regulated drugs, biologics, and devices and starting last
    September, began collecting summary results of trials of FDA-approved
    products. ClinicalTrials.gov currently contains data on more than
    70,000 trials in 166 countries and is searched by more than 500,000
    people every month.
        The NLM's two research centers collaborate on improving standards
    for genetic and genomic testing. The NCBI provides a database of
    reference values to assist in quality control of genomic tests. The
    Lister Hill Center is helping to expand the Logical Observation
    Identifiers Names Codes standard to cover genetic and newborn screening
    tests already in routine clinical and public health use.
        Electronic health records with advanced decision-support
    capabilities--and connections to relevant health information--will be
    essential to achieving personalized medicine and will also help people
    manage their own health. NLM supported much of the seminal research
    work on electronic records, clinical decision support and health
    information exchange. NLM is the HHS coordinating body for clinical
    terminology standards and supports development and dissemination of key
    standards for U.S. health information exchange. The Lister Hill Center
    is actively engaged in research on next generation electronic health
    records to facilitate patient-centered care, clinical research, and
    public health. This work has already resulted in tools that are helping
    system developers, including some at the Centers for Medicare and
    Medicaid Services, to incorporate the use of standards into health
    information systems.
                      information services for the public
        In addition to providing researchers and health care providers with
    access to scientific information, the NLM also serves the public--from
    elementary school children to senior citizens. The Library's main
    consumer health portal is MedlinePlus, available in both English and
    Spanish. In fiscal year 2008, there were more than 750 million
    MedlinePlus pages viewed by more than 132 million unique visitors from
    229 countries. In addition to more than 725 ``health topics,''
    MedlinePlus has interactive tutorials for persons with low literacy,
    medical dictionaries, a medical encyclopedia, directories of hospitals
    and providers, surgical videos and links to the scientific literature.
    A ``Go Local'' feature links users to information about services in
    their communities. Today, there is go local coverage for approximately
    44 percent of the U.S. population and expansion is an important goal
    for the Library in fiscal year 2010.
        In 2009, the NLM celebrated its second year of producing the NIH
    MedlinePlus magazine, an outreach effort made possible with NIH and
    Friends of the NLM support. The free magazine is widely distributed to
    the public via physician offices, libraries, and other locations, with
    a readership of up to 5 million nationwide. A Spanish/English version,
    NIH MedlinePlus Salud (the Spanish word for ``health''), was launched
    in January 2009 to address the specific health needs of the growing
    Hispanic population.
        NLM also produces an array of specialized consumer health Web
    resources. Genetics Home Reference provides understandable information
    about genetic conditions and related genes or chromosomes. The
    Household Products Database provides easy-to-understand data on
    potential health effects of more than 2,000 ingredients contained in
    more than 8,000 common household products. The Dietary Supplements
    Labels Database has information from labels of more than 3,000 brands
    of dietary supplements, with links to authoritative sources of
    information.
              ensuring access to information in times of disaster
        NLM is committed to ensuring uninterrupted access to critical
    information services in the event of disaster or emergency. NLM's new
    Disaster Information Management Research Center is building on proven
    emergency backup and response mechanisms within the NN/LM to promote
    effective use of libraries and specially trained librarians--disaster
    information specialists--in disaster management efforts. The Center
    also collaborates with the Navy National Medical Center, Suburban
    Hospital Healthcare System, and NIH Clinical Center in the Bethesda
    Hospital Emergency Preparedness Partnership. The Partnership will
    provide hospital surge capacity for the national capitol area and
    create a surge model for use across the Nation. Recent studies found
    such capabilities lacking in major metropolitan areas. NLM coordinates
    R&D for this model and investigates new methods for sharing health
    information for disaster preparedness and response.
        NLM also develops advanced information services and tools to assist
    emergency responders when disaster strikes. NLM's TOXNET, a cluster of
    databases covering toxicology, hazardous chemicals, and toxic releases,
    provides a foundation for services to first responders, such as
    Wireless Information System for Emergency Responders and Chemical
    Hazard Event Medical Management (CHEMM). CHEMM builds on the Library's
    successful collaboration with the HHS Office of Public Health
    Preparedness, the National Cancer Institute, and the centers for
    disease prevention and Control to develop the Radiation Event Medical
    Management (REMM) system. NLM is also developing a tool for
    identification of post traumatic stress disorder and mild traumatic
    brain injury.
        In summary, the NLM is well-positioned to contribute to the
    Nation's health--by making increasing amounts of scientific data
    available to researchers and health practitioners, by improving the
    Nation's healthcare information infrastructure, by providing the public
    with access to authoritative information to maintain their personal
    health, and by enabling health sciences libraries to make substantial
    contributions to disaster information management. All of these
    activities will depend on a strong and diverse workforce for biomedical
    informatics research, systems development, and innovative service
    delivery. To that end, the NLM will continue its longstanding support
    for postgraduate education and training of informatics researchers and
    health science librarians.
                                     ______

      Prepared Statement of Dr. Jack E. Whitescarver, Director, Office of
                                 AIDS Research
        Mr. Chairman and members of the subcommittee: I am pleased to
    present the President's fiscal year 2010 budget request for the trans-
    National Institutes of Health (NIH) AIDS research program of the NIH.
    The fiscal year 2010 budget includes $3,055,494,000, which is
    $45,155,000 more than the fiscal year 2009 appropriation of
    $3,010,339,000.
                               the aids pandemic
        More than 33 million people around the world are estimated to be
    currently living with HIV/AIDS infection. More than 25 million men,
    women, and children have already died.
        The pandemic affects the future of families, communities, military
    preparedness, national security, political stability, national economic
    growth, agriculture, business, healthcare, child development, and
    education in countries around the globe. As a result of multilateral
    and bilateral programs in low- and middle-income countries, almost 3
    million people now have access to antiretroviral drug treatment.
    However, for every 1 person who starts taking antiretroviral drugs,
    another 3 become infected.
        In the United States, HIV/AIDS remains an unrelenting public health
    crisis. The Centers for Disease Control and Prevention (CDC) reports
    more than 1.1 million people are infected with the virus, with
    approximately 56,300 new infections each year. According to CDC
    statistics, African-American men and women and gay and bisexual men of
    all races and ethnicities are the most affected groups in the United
    States. It is estimated that 1 out of every 20 individuals in the
    District of Columbia is HIV infected--a vivid example of the impact of
    AIDS on minority populations in the United States.
                      the trans-nih aids research program
        The NIH AIDS research program is the largest in the world--a unique
    and complex multi-Institute, multi-disciplinary, global research
    program. Perhaps no other disease so thoroughly transcends every area
    of clinical medicine and basic scientific investigation. AIDS research
    is carried out by nearly all of the NIH Institutes and Centers in
    accordance with their mission. This diverse research portfolio requires
    an unprecedented level of scientific coordination and management of
    research. The Office of AIDS Research (OAR) was authorized to plan,
    coordinate, evaluate, and budget all NIH AIDS research, functioning as
    an ``institute without walls,'' allowing NIH to pursue a unified
    research program to prevent and treat HIV infection and its associated
    complications. OAR has established comprehensive trans-NIH planning,
    portfolio analysis, and budgeting processes to identify the highest
    priority areas of scientific opportunity, enhance collaboration,
    minimize duplication, and ensure that precious research dollars are
    invested effectively and efficiently. The research priorities that
    frame this trans-NIH budget request were established through the annual
    OAR strategic planning process, involving scientists from NIH, other
    Government agencies, academia, industry, and nongovernmental
    organizations, as well as community representatives.
           fiscal year 2010 research priorities: prevention research
        Prevention of HIV infection is NIH's highest priority for HIV-
    related research. Disappointing results from recent clinical studies of
    HIV vaccine and microbicide candidates underscore the need for
    additional discovery (basic) research on HIV and the host immune
    response. Biomedical and behavioral interventions are urgently needed
    to reach individuals at risk, particularly in racial and ethnic
    populations in the United States, in international settings, among
    women, and among men who have sex with men. Priority areas include:
      --Microbicides.--Microbicides, antimicrobial products that can be
            applied topically for the prevention of HIV and other sexually
            transmitted infections, may offer one of the most promising
            primary preventive interventions. NIH supports a comprehensive
            microbicide research program that includes the screening,
            discovery, development, preclinical testing, and clinical
            evaluation of microbicide candidates, as well as fundamental
            research aimed at understanding how HIV transverses mucosal
            membranes and infects cells. NIH supports behavioral and social
            science research on the acceptability and use of microbicides
            among different populations. In fiscal year 2010, NIH will
            increase funding for the design, development, and evaluation of
            microbicide candidates.
      --Vaccines.--The best long-term hope for controlling the AIDS
            pandemic is the development of safe, effective, and affordable
            AIDS vaccines. AIDS vaccine research remains a high priority to
            ensure that new and innovative concepts continue to advance
            through the pipeline. NIH supports a broad AIDS vaccine
            research portfolio encompassing basic, preclinical, and
            clinical research. The disappointing results from clinical
            studies of the Merck HIV vaccine candidate indicate a critical
            need to reinvest in basic research studies on the virus and
            host immune responses that can inform the development of new
            and innovative vaccine concepts; as well as the development of
            improved animal models to conduct pre-clinical evaluations of
            vaccine candidates. In fiscal year 2010, NIH will fund
            additional basic research on HIV and host responses, as well as
            the design and development of new vaccine concepts and the pre-
            clinical/clinical development of vaccine candidates in the
            pipeline.
      --Behavioral Research.--NIH supports research to further our
            understanding of how to change the behaviors that lead to HIV
            acquisition, transmission, and disease progression--including
            preventing their initiation--and how to maintain protective
            behaviors once they are adopted. In addition, NIH supports
            research aimed at better understanding the social and cultural
            factors associated with HIV risk or protection, particularly in
            communities at high risk of HIV acquisition. This research will
            contribute to the implementation of a broader range of
            preventive and/or therapeutic strategies.
               fiscal year 2010 priorities: therapeutics research
        Antiretroviral treatment has resulted in improved immune function
    in patients who are able to adhere to the treatment regimens and
    tolerate the toxicities associated with antiretroviral drugs; and it
    has delayed the progression of HIV disease, extending the time between
    initial infection and the development of AIDS. However, a growing
    proportion of patients receiving therapy are demonstrating treatment
    failure, experiencing serious drug toxicities and side effects, and
    developing drug resistance. A critical area of research is the use of
    antiretroviral therapy as prevention. This includes evaluating the use
    of therapeutic regimens after exposure to HIV (postexposure
    prophylaxis), as well as testing the concept of the use of
    antiretroviral therapy in high-risk individuals prior to HIV exposure
    (pre-exposure prophylaxis).
        Epidemiologic studies have revealed a number of co-infections and
    co-morbidities associated with long-term HIV disease, including
    tuberculosis, hepatitis C, malignancies, metabolic disorders,
    cardiovascular disease, and neurologic disorders. A better
    understanding of the underlying etiology of these HIV-associated
    conditions will lead to better prevention and treatment strategies. NIH
    supports a comprehensive therapeutics research program to design,
    develop, and test drugs and drug regimens to prevent and treat HIV
    infection and its associated co-infections and co-morbidities.
        Translational and clinical studies also are needed to transform
    fundamental research results into improved strategies for preventing
    and treating these HIV-associated complications, including research on
    drug resistance, drug toxicities, pharmacogenomics, adherence, and the
    interrelatedness of HIV and nutrition.
                    discovery research: enabling innovation
        A renewed emphasis on discovery research is essential to enable
    innovation, address critical gaps, and capitalize on emerging
    scientific opportunities. Ground-breaking strides have been made
    towards understanding the fundamental steps in the lifecycle of HIV,
    the host-virus interactions, and the clinical manifestations associated
    with HIV infection and AIDS. However, additional research is needed to
    further the understanding of the virus and how it causes disease,
    including studies to delineate how gender, age, ethnicity, and race
    influence vulnerability to infection and HIV disease progression. NIH-
    supported genomics studies and breakthroughs in sequencing the human
    genome provide new opportunities to apply these valuable tools to the
    search for new HIV prevention and therapeutics strategies. OAR proposes
    to capitalize on those opportunities by providing funds for new,
    exciting areas of investigation, including studies utilizing genomics
    tools to investigate the immune response to HIV infection.
                    research training and community outreach
        NIH must continue to support training programs for United States
    and international researchers to build the critical capacity to conduct
    AIDS research both in racial and ethnic communities in the United
    States and in developing countries. NIH funded programs have increased
    the number of training positions for AIDS-related research, including
    programs specifically designed to recruit individuals from
    underrepresented populations into research careers and to build
    research infrastructure at minority-serving institutions in the United
    States. The changing pandemic and the increasing number of HIV
    infections among women and in racial and ethnic populations of the
    United States, particularly in African-American and Latino/Hispanic
    communities, also underscore the need to disseminate HIV research
    findings and other related information to communities at risk.
                                    summary
        NIH-sponsored HIV/AIDS research continues to provide the important
    scientific foundation necessary to design, develop, and evaluate new
    and better vaccine candidates, therapeutic agents and regimens, and
    prevention interventions. NIH will continue to focus on the need for
    comprehensive strategies to decrease HIV transmission and improve
    treatment options and treatment outcomes in affected vulnerable
    populations in the United States, and in international settings. These
    interventions will address the co-occurrence of other sexually
    transmitted diseases, hepatitis, drug abuse, and mental illness; and
    consider the role of culture, family, and other social factors in the
    transmission and prevention of these disorders.
        The NIH investment in AIDS research is reaping even greater
    dividends in unraveling the mysteries surrounding many other
    infectious, malignant, neurologic, autoimmune, and metabolic diseases.
    AIDS research has provided an entirely new paradigm for drug design,
    development, and clinical trials to treat viral infections. Drugs
    developed to prevent and treat AIDS-associated opportunistic infections
    also provide benefit to patients undergoing cancer chemotherapy or
    receiving anti-transplant rejection therapy. AIDS research also is
    providing a new understanding of the relationship between viruses and
    cancer. We are deeply grateful for the support the administration and
    this subcommittee have provided to our efforts.

        Senator Harkin. Dr. Kington, thank you very much for your
    opening statement, and I see we've been joined by Senator
    Shelby.
        Did you have an opening statement?

                     STATEMENT OF SENATOR RICHARD C. SHELBY

        Senator Shelby. Mr. Chairman, I'm glad to join you. I look
    forward to the hearing. I'll be in and out of here. We have
    some other Appropriations subcommittee hearings, but I do have
    a statement that I'd like to be made part of the record and I
    do have some questions that I'm going to have to leave and come
    back to ask those questions, unless you let me go.
        [The statement follows:]
                Prepared Statement of Senator Richard C. Shelby
        Mr. Chairman, thank you. I appreciate you having this hearing today
    to discuss the vital mission carried out by the National Institutes of
    Health (NIH).
        We live in a world where there are thousands of debilitating and
    life-threatening diseases--all that could use additional funding for
    research and clinical trials. We must continue to work towards the goal
    of increasing the overall Federal investment in basic research and
    development.
        I support additional funding for NIH research, but in particular, I
    would like to emphasize today the importance of accelerating research
    in the area of Cystic Fibrosis (CF).
        CF is a life-threatening genetic disease for which there is no
    cure.
        But there is promise for people with CF--and that promise is in
    research.
        Federal funding for medical research should accelerate the process
    of discovery and clinical development of new therapies for the
    treatment of disease. Yet, there is a significant discrepancy
    persisting between funding for clinical versus basic laboratory
    research.
        Support for clinical research is particularly important for rare
    diseases, which often suffer from a lack of start-up funding needed to
    overcome the initial discovery phase of drug development and move into
    advanced stages of research.
        Clinical research programs like the Cystic Fibrosis Foundation's
    Therapeutics Development Network have produced innovative new therapies
    for that disease. Led by research institutions including the University
    of Alabama at Birmingham, this national network allows multiple
    therapeutic approaches to be pursued simultaneously, accelerating the
    development of new treatments for the disease.
        Dr. Kington coordinated networks such as the Cystic Fibrosis
    Therapeutics Development Network provide special insights regarding the
    most efficient means of conducting clinical trials.

        Question: Will the NIH increase Federal funding for these
    types of research?  deg.
        Senator Harkin. I have some, but, I mean, if you have to go
    to another----
        Senator Shelby. Senator Mikulski and I have a NASA hearing.
        Senator Harkin. Well, why don't you go ahead then? I'll
    hold mine and you go ahead and ask your questions.

                                CYSTIC FIBROSIS

        Senator Shelby. Thank you, Mr. Chairman.
        Mr. Chairman, I thank you for the work you've done in
    chairing this subcommittee, and I continue to work with you.
        We live in a world where there are thousands, everybody
    knows this, especially our panelists, we live in a world where
    there are thousands of debilitating and life-threatening
    diseases and they all could use additional funding for research
    and clinical trials, and I believe we must work toward the goal
    of increasing the overall Federal investment in basic research
    and development, and I applaud Senator Harkin in his work in
    this regard.
        I personally, as a member of this subcommittee, support
    additional funding for NIH research, but in particular, today
    just for a few minutes, I would like to emphasize the
    importance of accelerating research in the area of cystic
    fibrosis.
        Cystic fibrosis, as the panel knows, is a life-threatening
    genetic disease for which there is no cure but there is promise
    for people and that promise is in research.
        Federal funding for medical research should accelerate the
    process of discovery and clinical development of new therapies
    for the treatment of this disease and others, yet there is a
    significant discrepancy existing between the funding for
    clinical research versus basic laboratory research.
        Support for clinical research, as I understand it, is
    particularly important for rare diseases which often suffer
    from a lack of start-up funding needed to overcome the initial
    discovery phase of drug development and move into advanced
    stages of research.
        Clinical research programs, like the Cystic Fibrosis
    Foundation's Therapeutics Development Network, have produced in
    the way of new therapies for that disease. Led by research
    institutions, including the University of Alabama at
    Birmingham, this national network allows multiple therapeutic
    approaches to be pursued simultaneously, accelerating the
    development of new treatments for the disease.
        Dr. Kington, coordinating networks, such as the Cystic
    Fibrosis Therapeutics Development Network, provide special
    insights regarding the most efficient means of conducting
    clinical trials.
        Under your leadership, will the NIH increase Federal
    funding for these types of research?
        Dr. Kington. Let me start off with a general answer and
    then I'll ask Dr. Nabel to comment, as well.
        Senator Shelby. Okay.
        Dr. Kington. I think, in general, we agree that there are a
    lot of opportunities for us to accelerate the translation of
    scientific advances in the basic level into real treatments and
    interventions and diagnostic strategies at the bedside. We know
    that there are particular challenges for less common diseases.
        In fact, we just announced yesterday a new initiative to
    help facilitate that translation and the Cystic Fibrosis
    community in many ways is held up as a good example of how a
    community affected by a disease can work collaboratively with
    the research community to facilitate translation and we're
    committed to helping that in any way we can.
        Dr. Nabel, would you like to comment, as well?
        Dr. Nabel. I appreciate your question. The NIH is very
    concerned about rare genetic disorders, like cystic fibrosis,
    and, indeed, I think if we can take a minute and really reflect
    upon the progress that's been made in cystic fibrosis, it's
    really been remarkable over the past decade.
        We've gone from discovering the gene which causes the
    majority of cystic fibrosis, particularly the mutation, the
    CFTR gene. We know now that that gene leads to a protein that
    doesn't unfold properly. This protein is responsible for
    clearing secretion in the airways and in other tissues and when
    that protein doesn't unfold it can't lead to the clearance of
    secretions, mucous builds up, that gets infected and the
    sequela start.
        What's very interesting is that the gene led to the
    understanding of what we call the molecular pathway that causes
    the disease. Understanding that molecular pathway then led to a
    search for new therapeutics that perhaps you're familiar with,
    and that search has now come up with two compounds, we call
    them small molecules, that are in clinical testing which
    directly affect the molecular pathway and, indeed, you probably
    saw Dr. Rootman's article in the New Yorker a couple of weeks
    ago and the remarkable report by several individuals who were
    enrolled in those trials saying how well they feel while taking
    these new drugs.
        So that is, I think, a terrific example of how gene
    discovery leads to understanding, the molecular pathway leads
    to the detection of new therapeutics that are now being tested.
        Can we do more in this area? Absolutely, absolutely. We're
    hoping to increasingly fund translational research and new
    clinical research in this area. The NHLBI currently has a
    specialized center for clinically oriented research in cystic
    fibrosis that's analogous to the CF Clinical Networks that you
    described and so many of those investigators are really the
    same community of folks.
        But we look forward to really building and augmenting this
    research effort going forward.
        Senator Shelby. Well, I appreciate this. I know you have to
    start in the lab, but then you've got to move from the lab to
    the clinics to prove what's going on. So we have to have both,
    do we not?
        Dr. Nabel. Absolutely.
        Senator Shelby. Well, I look forward to working with you,
    not just on cystic fibrosis, this is my attention for the
    moment, but in a lot of other diseases, and with Chairman
    Harkin in this regard.
        Mr. Chairman, thank you for taking me out of order, but you
    know from chairing the subcommittee and being on other
    subcommittees, we sometimes meet at the same time.
        Thank you, Mr. Chairman.

                              SUCCESS RATE OF ARRA

        Senator Harkin. Thank you, Senator Shelby, and thanks for
    all your involvement in this subcommittee over many, many years
    in research, medical research. So thank you very much for that.
        Well, Dr. Kington, I want to talk about the Recovery Act
    and that money, and our budget. The problem is that the flip
    side of having all these requests come in is that most of them
    will not be funded. I'm hearing that the success rate for the
    Challenge Grants could be less than 5 percent.
        So how do you keep up a high level of interest when so few
    researchers will actually get these grants? On the one hand
    it's a good thing. On the other hand do you discourage a lot of
    people when they don't get funded?
        Dr. Kington. This is definitely a concern of ours. It's
    been interesting to read some of the press coverage which
    reporters have gone out speaking to scientists and we were
    pretty clear early on that we had a floor for dollars and that
    suggested that we would not have our usual success rate because
    this was a special program.
        In spite of that, the scientists saw this as an
    extraordinary opportunity to actually get on paper interesting
    ideas in important areas. We believe that even with the
    substantial increase, I predict that we'll more than double
    that floor of $200 million, we still won't have a high success
    rate and there will be many good grants that we won't be able
    to fund, and there will be consequences for the agency and for
    the scientific community.
        We anticipate that many of the scientists will resubmit
    those applications within our usual funding sequence. We
    suspect that we'll be able to fund some of them but our ability
    to fund even the very best of those applications will depend
    upon what our budget is in future years.
        So it's a concern. I think at the very least it shows this
    extraordinary untapped supply of great ideas out there in the
    scientific community and I see that as a good thing.

                            ARRA AND FUTURE SUPPORT

        Senator Harkin. It seems to me that concerning the program
    you talked about, the Grant Opportunity Program, the GO Grants,
    it is my information that the purpose of this program is to
    support high-impact ideas that require significant resources
    for a discrete period of time to lay the foundation for new
    fields of investigation, Yet out of that $10.4 billion, $200
    million is designated to GO Grants.
        It seems to me that if you put most of the money in the RO1
    grants and you do it for 2 years rather than 4 years, what
    happens after 2 years? Are you just sort of betting out on the
    cow that we're going to be able to keep that funding up?
    Because I'm not certain that we can.
        I guess my question is, since this was a certain amount of
    money for a discrete period of time and you have these grants
    as I just defined them, why wouldn't I see more of that money
    going to that rather than RO1 grants for 2 years?
        Dr. Kington. First of all, I think you'll see across the
    Institutes and Centers wide variation in whether or not--in how
    the dollars are distributed across these mechanisms and the
    numbers that we put forth were a floor.
        I anticipate that the number will be higher because many
    Institutes, NHLBI and others, are increasing their commitments
    already to that stream of dollars and it will depend upon what
    ideas we see.
        This was again a grand experiment in many ways to put out a
    broad call to see what the best ideas were and not restrict it
    to dollars, $1 million which was the limit for the Challenge
    Grants.
        So the bottom line is that we think that we'll ultimately
    end up funding more than what we had initially planned. We
    believe that it's important to allow flexibility across
    Institutes and Centers. For some Institutes and Centers, these
    types of programs will be great opportunities. For others,
    scientifically it's a stronger case to fund more of the RO1s,
    but again even the RO1s, our estimate is that about, I think,
    one-third or so of the dollars probably will go to the existing
    pool of RO1s, but it varies from Institute to Institute.
        Our goal is to make the framework as flexible as possible,
    but if we have great ideas, we'll put more resources toward the
    GO Grants and we are anxiously awaiting the applications. We
    anticipate that we'll get probably--I anticipate probably
    around 2,000 or so applications when all is said and done and
    if they're great ideas, we'll do our best to fund them.
        Senator Harkin. That's the GO Grants? That's what you're
    talking about?
        Dr. Kington. Yes, the GO Grants, and again we suspect that
    many of these ideas that aren't funded but are still good will
    be resubmitted and our ability to fund those will depend upon
    what our budgets are in the out years.
        We'll make the best decisions we possibly can to have the
    maximum impact of these dollars for science and public health,
    but again I see this in a very positive light, that we have had
    this extraordinary energized response by the scientific
    community.
        It really is amazing, speaking to deans and faculty across
    the country, how excited the scientific community is both about
    the opportunities, the real opportunities to do work they
    otherwise couldn't have done, but perhaps even more
    importantly, about what these dollars said as a reflection of a
    commitment of the country to invest in biomedical research.
        Senator Harkin. Let me ask you this question. If, in the
    wisdom of Congress, it was decided that this money was to go
    out over 2 years, right?
        Dr. Kington. Yes.
        Senator Harkin. But that's not to say we can't change our
    minds and it happens.
        Dr. Kington. Congress can do whatever Congress wants.
        Senator Harkin. We can change our minds. It's occurred to
    me that, yes, we initially put that out there to be 2 years,
    but maybe we might want to think about making an exception for
    NIH, that maybe this money should be more than just a 2-year
    period of time.
        Is that something that you could live with? I mean, would
    that help in any way or is it so set now for 2 years that we
    ought to just leave it alone? Rather than thinking about maybe
    changing it to provide for a longer period of time, say 4
    years, to get that money out or something?
        Dr. Kington. Well, we certainly made all of our decisions
    based thus far on a 2-year time horizon, but I will concede
    that having more flexibility probably would be helpful, but we
    also recognize the unique intent of these dollars and that is
    to stimulate the economy in the short run, and we believe we
    can responsibly spend the money in 2 years.
        But some flexibility might help us as we sort of work
    through the process of spending. We might be able to have a
    benefit from more flexibility, but we will make good decisions
    even without that flexibility.
        Senator Harkin. Well, I might come back to you on that, not
    in this hearing but later on, to see if that flexibility might
    be the best course of action for us to take. Like I said, I
    don't know. It's just something I've thought about because
    again I just want to see how we judge the success of the
    Recovery Act funding.
        I mean $10.4 billion within 2 years, but a lot of the
    results of that won't be known for some time. So I assume that
    a lot of people say we can judge the success on how many jobs
    it's created perhaps, if we're looking at it stimulating the
    economy. That's why the amount of money you put out there for
    extramural construction is important and getting new equipment
    in our labs is important, but I think a lot of the success of
    this will be judged, not just on the immediate jobs created but
    what's the long-term effect of the money that we provided?
        So people say, ``Did we get our money's worth?'' Well,
    that's what's led me to think maybe--and I'm not saying this
    could happen--but maybe we ought to think about more
    flexibility in that 2-year time frame because I'm really
    worried. I say this to all of you. I'm really concerned about
    the cliff.
        What's going to happen in 2011? We've got 2010, what 1.4
    percent? 1.4 percent increase. You had it up there on the
    screen. But we funded $30.8 billion, but what happens in 2011
    when--if all these Recovery Act funds come out? I mean that's
    going to be a pretty hard landing, it seems to me, and, you
    know, I'm thinking about how do we soften that because I think
    we might be in a tough budget situation next year as we are
    this year and so since we've already appropriated this money
    for the Recovery Act, that we might think about trying to
    soften the landing a little bit. If you have any thoughts
    beyond that, of how we soften this a little bit, I'd like to
    know it, either today or maybe in writing or something later
    on.
        Dr. Kington. We'd be happy to do that, and actually I'd
    welcome any of my colleagues. Just as all politics is local,
    all science is sort of local, as well, and many of--all of the
    Institute and Center directors are struggling with this exact
    same issue of how to responsibly make decisions now,
    recognizing the uncertainty about the future streams of
    dollars.

                 SUPPORT OF PROMISING RESEARCH AND FLEXIBILITY

        Senator Harkin. This is my chance to ask all of you here
    some questions. I'll start with Dr. Fauci.
        Can you point to anything that your Institute is able to do
    now or can start and finish in 2 years? Is there something that
    you're able to do now with this Recovery money that you weren't
    able to do?
        I'll ask each of you that. Dr. Fauci, any specific examples
    of research that you're able to fund that you otherwise might
    not have been able to?
        Dr. Fauci. Thank you for the question, Mr. Chairman. There
    are examples of things that we would not be able to fund if we
    didn't have it and there are examples of things that we can
    greatly accelerate and we would be able to use monies later on
    that we could continue it.
        The example that I give is one of about three or four, and
    I'll only give one, is the money that we're putting in to
    accelerate the process of much more aggressive control of the
    HIV pandemic related to some novel and important research
    questions that need to be answered, as bold as trying to
    develop a functional cure for HIV to accelerating the process
    of what we call pre-exposure prophylaxis where you actually
    treat individuals who are in high-risk groups before they get
    infected.
        There is a lot of research--it seems like a very
    interesting and important concept, but there are some very
    important research questions to be asked--Does it work? What is
    the relationship to adherence? Would it lead to resistance? If
    we can prove the concept, then that concept could transform how
    we prevent HIV infection.
        And the last part of that triad is something that we call
    test and treat which the money for 2 years will help us
    accelerate the research endeavor in that we would not be able
    to do as quickly and we're committed to seeing it to fruition
    and the test and treat is a very bold concept that was put
    forth by a group at the World Health Organization about a half
    a year ago and that is to essentially test everybody and those
    who are infected, to actually treat them, regardless of where
    they are in the stage of the disease, with the thought that if
    you get the viral load low enough, they will then not infect
    other people.
        That is a very bold concept that will require globally a
    lot of resources, but the world is looking to the NIH to prove
    the feasibility of that concept and we're going to do that in a
    much more rapid way by the money that we have decided to use
    from the ARRA allotment to get that jumpstarted.
        Senator Harkin. You can't complete that in 2 years, surely,
    though, can you?
        Dr. Fauci. I might echo what Dr. Kington said. Flexibility
    in my mind is always something that would be helpful to us, but
    we still can get a lot done in the 2 years, but if we had more
    flexibility that would be advantageous to the program.
        Senator Harkin. Okay. Dr. Nabel.
        Dr. Nabel. Thank you, Senator Harkin. I'm going to provide
    you one example of something that we couldn't do without the
    ARRA money and then another example of things that we can
    accelerate.
        We will use ARRA monies as one-time money to expand our
    understanding of the genetics of complex diseases. I think this
    will apply across many of the Institutes but it will certainly
    apply to Heart, Lung, and Blood.
        For example, over the years you've probably heard from
    NHLBI and ARRA, my predecessors, about the many large, what we
    call, cohort studies that the NHLBI has studied, the Framingham
    Heart Study, the Jackson Heart Study, our Hispanic Heart Study.
        We've gathered beautiful clinical data for decades, in the
    case of the Framingham Heart Study 60 years. We now can take
    that data and combine it with the genetic understanding of the
    disease to gain new insights into the causation of blood
    pressure, cholesterol, asthma, COPD, and that's what we intend
    to do through some of our GO Grants, is to conduct more
    extensive genetic analysis of these large cohorts which you
    have helped us to support over the years. That's a one-time
    activity that we probably could not have afforded to do without
    the ARRA monies.
        In terms of accelerating medical advances, I think Senator
    Shelby really hit the nail on the head. What we can do with the
    ARRA money is now begin to accelerate our translational
    research program. This infusion of money really helps us to
    focus on a number of mechanisms by which we can help our
    investigators speed, accelerate the basic advances into
    clinical trials and in fact, in terms of the Challenge Grants,
    I think our particular Institute, the last I heard, there was
    somewhere between 1,900 and 2,000 Challenge Grants just for the
    NHLBI.
        We will supplement what Dr. Kington will fund from the
    Office of the Director, but many of these are focused on
    translational research and so we see this as an opportunity now
    to jumpstart.
        We have one particular clinical trial, we call it SPRINT.
    For many years we thought the target for blood pressure
    lowering should be 140 over 80 but, you know, that might not be
    the right target. Maybe we should go a little lower. Maybe if
    we went lower, we could actually reduce some of the age-related
    effects of high blood pressure.
        So SPRINT is to look at lowering down to 120 over 70, even
    120 over 60 as the potential target. We want to look at this in
    adults and, importantly, we want to look at this in our
    adolescents and our children.
        You know one of the complications of obesity, many of our
    kids are becoming diabetic and hypertensive at a very young age
    and so this ARRA money will help us speed and accelerate the
    start of that clinical trial, extend it to a broader
    population, but yes, and then we'll need to fund the out years
    through appropriated dollars, but that's another example of a
    very important public health program that we can jumpstart,
    accelerate with ARRA monies.
        Thank you.
        Senator Harkin. Dr. Niederhuber----
        Dr. Niederhuber. Thank you, Senator Harkin.
        Senator Harkin [continuing]. Tell us about cancer.

                             CANCER AND ARRA FUNDS

        Dr. Niederhuber. I think I'll echo flexibility. I think
    that would be helpful to all of us.
        But we have some great opportunities, as you know, in terms
    of novel agents that have been developed but have not yet been
    able to move into the clinical trials arena, our early phase
    translational research, and so we're going to use a significant
    amount of these stimulus dollars, Recovery dollars to actually
    really jump into the clinic with early phase, first-in-man
    studies in a number of these new agents. I think that's going
    to have a significant impact.
        Perhaps even more importantly than that is we have had a
    very successful pilot project that you're aware of, we call it
    TCGA, in which we've been actually developing the
    infrastructure to do complete sequencing of cancer. We've had
    three cancers in that pilot program, glioblastoma, ovarian
    cancer, and small cell lung cancer.
        We've already found some extremely exciting discoveries in
    doing the sequencing, for example, of glioblastoma, genes that
    are related to that tumor that we didn't know were related to
    that tumor in the past.
        I have a group of scientists meeting as we speak, yesterday
    and today, in San Francisco, that are analyzing our data on
    ovarian cancer and they tell me by phone some very, very
    exciting discoveries are coming out of that sequencing project.
        So, clearly, this is telling us that the direction that we
    need to go in is to scale this up and that's what we're
    planning to do and the Recovery dollars will be a great help in
    our jumpstarting to do other tumors, to do them on a larger
    scale.
        Without question, if we're going to repair this problem, we
    need to catalog all the defects and the technology is moving so
    quickly now that we will be able to do that and do that quite
    effectively over the next few years.
        So these Recovery dollars are extremely important to our
    ability to really scale that up. It's true in cancer but it's
    true really in all of the diseases that you see here at the
    table and represented behind me.

                              RESEARCH PRIORITIES

        Senator Harkin. Okay. A couple of other areas I just wanted
    to cover with you today. Of the $442 million increase proposed
    for NIH, $268 million would go for cancer research, $19 million
    would go for autism research. That leaves $155 million for
    everything else, heart disease, Alzheimer's, diabetes, AIDS,
    stroke, Parkinson's, on and on and on. I want to know if that
    makes sense.
        You know, I know the statistics on cancer. I've fought as
    hard as anyone for more money for cancer research, but there
    are other devastating diseases, too, and we hear from these
    groups almost on a daily basis.
        So when we're looking at a small increase, just 1.5
    percent, should we put so much of that into just one disease
    rather than spreading it out more? So there you go.
        Dr. Niederhuber, I don't mean to pick on you, but you're on
    the point on this. I'm saying, you've got a lot of the Recovery
    monies, but apart from that $442 million, I just question
    whether so much of it ought to go to two entities.
        Dr. Kington. Why don't I start off?
        Senator Harkin. I'll leave that to Dr. Kington. Go ahead.
    Did you want to start off?
        Dr. Kington. I'll take this one. As you noted, both cancer
    and autism are important public health challenges. These were
    priorities of the administration and the President and they're
    important priorities, and it's also important to note, though,
    that science in cancer is funded by every single Institute and
    Center. So it's not just Dr. Niederhuber. Every Institute and
    Center of the agency funds research related to cancer and we've
    initiated a strategic planning process, co-chaired by Dr.
    Niederhuber and Dr. Katz, to bring together all of the agency
    to think about how to develop a plan for increasing this
    investment in cancer.
        It's also important to know that advances in cancer can
    help us learn more about basic biology in ways that would be
    useful for other diseases, as well.
        Senator Harkin. Well, that can be true of just about any
    disease.
        Dr. Kington. That's absolutely true. Your point is well
    taken.
        Senator Harkin. So again, I'm back to square one. Is this a
    fair allotment of money? Any other observations on that? Do we
    have to decide ourselves how to allocate this money up here?
        I just throw it out there because obviously we're trying to
    respond in a way to the legitimate interests of a lot of people
    out there suffering from these illnesses and we've made great
    advances in a lot of areas.
        For instance diabetes, we have made some tremendous
    advances in diabetes research and others that I mentioned and
    taxpayers obviously have a right to question that we're putting
    all of the money in one area.
        So I understand that, and I think that those of us here
    know that the administration proposed this, but we may have a
    different view on that. That's what I have to say about that.

                            OVERSIGHT OF OBJECTIVITY

        Now, there are a couple of other things I wanted to bring
    up.
        Last year my colleague, Senator Grassley from Iowa on the
    Finance Committee, requested some investigations into conflicts
    of interest. In fact, I just saw him this morning. We talked
    about it again, and he's still looking into that, his staff is
    looking into that, and we hear about it periodically. It comes
    up in the press or something like that, that some extramural
    researcher has gotten large payments from a private company
    that could be a potential conflict of interest.
        In the fiscal year 2009 omnibus appropriations bill, I
    included a provision that required HHS to issue ``an Advanced
    Notice of Proposed Rulemaking'' which will start the formal
    process of revising the guidelines. The public comment period
    for that process started earlier this month.
        So I was disturbed to see an article last week in The
    Chronicle of Higher Education in which an NIH official, I think
    unnamed, is quoted as saying, ``We can't say definitely we
    would change the regulations.''
        Well, I don't know. Is that an authoritative statement? I
    hope not. I don't think that the present situation is working
    very well right now. So something has got to be changed here on
    this, Dr. Kington.
        Dr. Kington. First of all, we absolutely share your
    commitment to having the agency playing a central role in
    assuring that there's objectivity in the science that we
    support which is the key issue here, assuring that first-rate
    science of the highest quality, objective science, is funded
    and produced.
        We also recognize that there have been a number of cases of
    investigators that we believe may not have complied with our
    regulations and as almost all of the associations that have
    looked into this, as well, have concluded, we think that there
    are opportunities to strengthen our system of oversight.
        The first step in that process is this Advanced Notice of
    Proposed Rulemaking and I think that the quote--well, I know
    the quote was taken out of context because, technically, the
    whole point of starting this process is to ask the question and
    for us to presume at the beginning the answer might raise
    serious questions about the whole process and so I think it was
    a technical response.
        I think we've said, I've said personally in a number of
    settings, as well, that we believe that there are opportunities
    to strengthen our system of oversight. There are things that
    we're doing within our current regulation to do just that--
    increase training and education and strengthening our reporting
    system. There are lots of things that we're doing now to change
    fundamentally and improve the way we oversee management of
    conflicts of interest.
        We're committed to doing that in the future and we will
    take seriously all the comments that we anticipate receiving
    under this Advanced Notice of Proposed Rulemaking and we're
    committed to doing the right thing.
        Senator Harkin. Well, I appreciate that. I think we have to
    be more positive in our approach on this, and on looking at
    these potential conflicts of interest.
        I've been on this subcommittee a long time and I know how
    difficult it is sometimes because a lot of research is paid for
    by the private sector, by the private drug companies, and it's
    good, valid research, and so how do you divide a researcher
    that has an institute--not an nstitute, but has a lab and
    they're getting some private money in and--but then they also
    qualify for an NIH grant. How you separate that out sometimes
    is pretty darn difficult. So I understand that.
        I'm more interested in the conflict of interest in which a
    person receives monetary income for their own bank account. I'm
    not so much interested in the lab itself and that money. I'm
    interested in what an individual might get paid by a drug
    company or something like that and when they are looking at
    certain drugs, for which they then recommend certain courses of
    action.
        This has to do with, I think, anti-psychotic drugs mostly
    and that this individual had been involved in researching it
    but also--maybe this is a bad choice of words, but promoting
    the use of these anti-psychotic drugs.
        I bring this up because I know that my colleague, Senator
    Grassley, is going to continue to look at this, as he should,
    and we have to. We have to be cognizant of this issue and do
    our best to answer those problems.
        Dr. Kington. Yes.

                                    H1N1 FLU

        Senator Harkin. The other thing I wanted to ask, Dr. Fauci,
    and it's sort of a replay of what we went over a couple weeks
    ago when you were up here, this H1N1.
        Where are we now? What are you seeing? Is it kind of
    dwindling now here?
        There was some talk that it might move to the Southern
    Hemisphere because of wintertime there, then it might come back
    here again this winter in a more virulent form. I keep
    wrestling with this problem of developing a vaccine because
    some of the money that we put in this was to develop a new
    vaccine. But again if we develop a new vaccine for the H1N1
    strain that we see now, but then it comes back this fall and
    it's different, how are we going to be certain that the vaccine
    we develop this summer is going to be effective against the
    strain of flu that might come back this fall?
        I'm still wrestling with that. I still don't understand
    that.
        Dr. Fauci. Okay. So three questions you asked me.
        Senator Harkin. Okay.
        Dr. Fauci. The status, vaccine, and does it change?
        Senator Harkin. There you go.
        Dr. Fauci. Okay. The status of the outbreak right now is
    that there's still considerable flu activity with H1N1 in the
    United States and worldwide. A recent outbreak that you read
    of, I know, in Japan. So there's considerable activity still
    going on.
        The CDC estimates that even though there are about 6,000
    reported cases that are confirmed or probable in the United
    States, it's likely that there are close to 100,000 people that
    have been infected. You don't pick them up because much of the
    illness is mild illness, yet there are some serious cases,
    which causes us to have an appropriate amount of attention to
    following this.
        As I mentioned to you a couple of weeks ago, this is a
    brand-new virus. It's an H1N1 but a different kind of an H1N1.
    It has swine origin as well as some avian and human origin. It
    is brand new. So the inherent unpredictability of influenza is
    compounded by the fact that we're dealing with a virus that
    we've never had any experience with before.
        Fortunately for us, we're going into a summer season when
    the conditions, the physical conditions for the spread of an
    influenza are minimized, but that doesn't mean that we still
    are not going to have some considerable problems.
        So the bottom line is that this outbreak is still in a
    dynamic stage and it's not over for us yet for the immediate
    period of time.
        What about the concern of what it might do? The fact that
    it's out there and it has already manifested its ability to
    spread from human to human here in the United States, Mexico,
    Canada, Europe, Japan, et cetera, that the concern is that we
    have to watch this very carefully from two standpoints.
        What happens in the Southern Hemisphere in the next month
    or two when they enter into their fall and winter, and we're
    going to watch that very closely because it will tell us what
    might happen to us next fall and winter for our seasonal flu
    vaccine time. The reason is that what usually happens, not
    always but usually is that the Southern Hemisphere flu activity
    is generally a good reflection of what might happen to us in
    the Northern Hemisphere in the following season. So we're
    looking at that very, very carefully.

                                    VACCINES

        Vaccine. The process of developing a vaccine has already
    begun and as I mentioned to you before but just to reiterate it
    very briefly, it's a multistep process and there are points in
    that process where there's a decision point, a go or no go.
        The first thing you do is you isolate the virus. That's
    been done. You start to grow it up as a reference strain or
    seed virus. The CDC is very actively involved in this and
    should have seeds ready to go out within a reasonable period of
    time. The prediction is by the end of this month. Hopefully
    that will be on time.
        Once that goes to the pharmaceutical companies, then they
    make pilot lots for clinical trials which is where the NIH
    comes in because then we have to ask the question: is it safe,
    does it induce an immune response that would be predictive of
    being protective, and what's the right dosage and the number of
    doses? At the same time, the companies will then start to, were
    the decision to be a go decision, to start to scale up.
        Your concern that bothers you is that if we're starting to
    make a vaccine for a virus that's circulating now and would
    likely return again in the fall and winter, what happens if it
    changes?
        Senator Harkin. Yes.
        Dr. Fauci. That's always a possibility. The likelihood of
    it changing so much that a vaccine that we're making now would
    be essentially noneffective is small, not zero, but it's small.
    That's the reason why the way we set it up in the department
    with the CDC, FDA, and the NIH is for multiple decision points
    along the way whether to make it, how much to make and whether
    to administer it.
        I will point out to you that every year when we make a
    vaccine for seasonal flu, put aside the pandemic for a moment,
    there's always the risk that the vaccine that you decide to
    make, that what happens to you the next season, it will change
    enough not to make a vaccine as effective as you want.
        Historically, most of the time we get it right. So we are
    hoping that we will get it right. I think we will. I don't
    think there will be that much of a change, but as I mentioned,
    influenzas are characterized by their unpredictability, but
    you've got to go with the science that you have, and the
    science that we have now tells us that this virus that's out
    there hasn't really changed much over the months that we've
    been following it.
        It started off in Mexico, the first detection in Mexico. We
    don't know where it started, but the first detection was
    somewhere in March or so. So we're now a few months into it and
    the virus seems to be pretty much the same as it's been. It's
    stayed relatively stable. That doesn't mean it's going to stay
    that way over the next year, but it has not drifted a lot.
        Senator Harkin. I keep hearing that even the seasonal flu
    vaccine may offer some immunity.
        Dr. Fauci. No.
        Senator Harkin. No?
        Dr. Fauci. No. This is good news for you, Senator, and me,
    and that is, it doesn't have--the vaccines that have been used
    seasonally don't appear to induce antibodies that strongly
    cross-react at all with the H1N1 that's the new novel H1N1.
        But what we are observing is that in the community this
    virus seems to be selectively more preferentially affecting
    young people. So the question is, Do old people--older people--
    have in their body some antibodies or cell-mediated immunity
    that they acquired from previous exposures to H1N1s over the
    previous years that are a bit below the radar screen, but that
    seem to be giving some protection? That's one of the prevailing
    theories, not proven yet, of why we're seeing it much more in
    young people.
        In fact, when you measure the antibodies in older
    individuals, a rather significant percentage of them have some
    cross-reactivity with the virus that's circulating now and the
    most obvious, though not necessarily proven, but the most
    logical reason for that is that they've been exposed over the
    last few decades to an H1N1 that has some similarity to the
    H1N1 that we're seeing now.

                               BARKER HYPOTHESIS

        Senator Harkin. Well, I'll have to correct some of the ways
    I've been saying things then because I've been led to believe
    maybe some of the immunities we have comes because we've gotten
    the seasonal flu shots over the last few years, but that's not
    it. It has to do with our exposures to the influenza virus some
    time in the past and we've developed antibodies to it. I'll
    have to correct the way I say that now.
        There's only one other area I just want to get into.
        First, you all know that we've been working very hard on
    healthcare reform and the area that I've been involved in, of
    course, and I've been harping on this for many years is getting
    into prevention and wellness and focusing on that. I think
    we're going to have some, I hope, great success in the health
    reform bill in moving in that direction, which leads me to this
    next question, and it has to do with some of the information my
    staff has given me and I've been reading about it, the so-
    called Barker Hypothesis.
        Dr. Barker of Oregon Health and Science University, who did
    a study that was very interesting--no, sorry, he didn't do a
    study. He examined other studies and came to some interesting
    conclusions, that pre-natal care--how you're taken care of
    before you are born may have a great impact on what happens to
    you later in life.
        My first initial reaction when I read that was, of course,
    if you have a low birth weight baby that means you don't get
    the right kind of nutrients and support during pregnancy. This
    happens sometimes in poorer families. I can understand that.
        But then evidently Dr. Barker factored that in and had
    accounted for that in his studies. And even accounting for
    that, it shows up that if you have a low birth weight baby,
    there were certain twins they followed the one that had the low
    birth weight had the most problems later on in terms of
    diabetes, stroke, hypertension, all kinds of things.
        So I guess my question is to maybe any body sitting there
    is, are we doing research? I've just come across this in the
    last few months and I wonder, are we looking into this? Is NIH
    doing any research in this area?
        Dr. Kington. Yes, we are. David Barker is a British
    physician who in the 1980s began to notice patterns of tracking
    of looking geographically at mortality rates in England,
    patterns of mortality that tracked adult cardiovascular
    mortality with infant birth weight and that was the beginning
    of this long line of research that has been supported by the
    agency, including by NICHD, and there are a range of evidence,
    some--most supported but some not supported, of this hypothesis
    that has evolved into a more complicated discussion about
    potential ways in which the intrauterine environment sort of
    sets trajectories by turning on or off genes or somehow setting
    trajectories that actually are manifest in late life but start
    off this trajectory.
        The hypothesis is that there's something unique going on in
    these early stages and it has implications for this entire
    continuum of potential causal pathways, from smoking now all
    the way back to shortly after conception and what happens in
    the intrauterine environment.
        It's an interesting hypothesis and generated a great deal
    of discussion, both in Europe and in the United States, and we
    fund research related to it. I think it's still to be
    determined what the implications are for intervention and what
    we do clinically, the argument being that if we know more about
    what happens in the intrauterine environment, we might
    intervene in ways beyond the obvious of good nutrition and
    prevention and all the things that you noted, better social
    environments and all the things that we know are good for
    starting off children beginning healthy lives.
        So the jury is still out about what the implications are,
    if it's correct, and there's a growing evidence base both in
    humans and in animal models, and we're supporting research and
    looking forward to seeing more advances in this area and we'd
    be happy to sort of synthesize some of the findings that we've
    supported and get back to you about that, as well.
        [The information follows:]
                             The Barker Hypothesis
        David Barker, an English epidemiologist working at the University
    of Southampton, noted that the geographical regions of the British
    Isles reporting high rates of death from coronary heart disease were
    the same regions that reported high rates of low birth weights. In a
    landmark study published in the medical journal Lancet in 1989, Dr.
    Barker and his colleagues reported on an analysis of serial data
    collected on 5,654 men in Hertfordshire. They found that the men with
    the lowest weights at birth had the highest death rates from coronary
    artery disease. Those with the lowest birth weights had more than twice
    the mortality rate than those with the highest birth weights.
        In seeking to explain the remote outcomes of low birth weight, Dr.
    Barker developed the Barker Hypothesis, which states: environmental
    factors that impair growth and development during fetal life and early
    infancy are risk factors for hypertension, type 2 diabetes, stroke, and
    coronary disease later in life.
        A general explanation for these findings is that birth weight
    represents an integral of all events that affect development during
    gestation, including nutrient supply, vascular sufficiency, infection
    and stress. The key question is to determine mechanistically what
    happens to the fetus to alter permanently its physiology and metabolism
    throughout later life.
        Studies in animal models are useful in revealing the physiological
    connections between impaired intrauterine growth and chronic disease
    later in life. Dr. Lori Woods at the Oregon University of the Health
    Sciences has shown that reduced maternal protein intake in a rat model
    impairs the development of the kidney in the offspring, leading to
    hypertension later in life. In a baboon model Dr. Peter Nathanielsz at
    the University of Texas at San Antonio has shown that nutrient
    restriction during fetal life leads to impaired development of insulin
    manufacture by the beta cells of the pancreas, predisposing the animals
    to type 2 diabetes later in life.
        The most widely accepted mechanism that explains these
    relationships is the metabolic adaptation that the fetus makes to
    survive in an intrauterine environment impaired by nutrient
    insufficiency, such as an increased secretion of cortisol. The survival
    mechanisms that are useful in the uterus, however, are maladaptive in a
    plentiful nutritional environment after birth as reported by Barker and
    his colleagues in two articles in the New England Journal of Medicine
    in 2004 and 2005. The first showed that low birth weight babies in an
    East Indian population who gain weight rapidly after birth are at high
    risk of developing type 2 diabetes in their third decade of life. The
    second showed that Finnish boys and girls with low birth weight are at
    increased risk of coronary artery disease later in life, especially
    those whose tempo of weight gain is greatest in the first decade of
    life.
        The Barker Hypothesis has stimulated new fields of related research
    on the effects of inimical environmental influences on the development
    of the brain and body during fetal life and early childhood. One line
    of investigation suggests that over-nutrition during pregnancy also can
    have untoward effects on offspring later in life. The NIH Obesity
    Research Task Force has identified this area as a research priority in
    regard to the development of type 2 diabetes, lipid disorders, and
    other metabolic disease in offspring. Studies in nonhuman primates have
    shown that consumption of a high fat-high calorie diet during pregnancy
    results in extensive fatty liver disease in the offspring, a disorder
    being seen with increasing frequency in obese adolescents. Maternal
    obesity has been reported to increase the risk of congenital defects,
    particularly neural tube defects, in developing offspring.
        Other studies suggest that high levels of blood sugar during
    diabetic pregnancies affect an offspring's risk of obesity and type 2
    diabetes later in life. NIH intramural investigators have shown in the
    Pima population of Arizona that type 2 diabetes in the mother leads to
    increased risk for type 2 diabetes and obesity in the offspring.
    Adverse effects of intrauterine exposure to diabetes were also shown
    recently in a racially and ethnically diverse population of youth; the
    NIH- and CDC-supported SEARCH study found that children with type 2
    diabetes received their diagnosis at an earlier age if their mothers
    had been diagnosed with diabetes prior to pregnancy.
        Another interesting line of research stimulated by the Barker
    Hypothesis involves the influence of maternal infections and
    intrauterine exposure to environmental agents on the development of
    disease in the offspring later in life. Dr. Alan Brown and colleagues
    at Columbia University have shown that maternal infections with strains
    of influenza virus type A and B during the first trimester of pregnancy
    increase the risk of schizophrenia spectrum disorders in the offspring
    later in life. They also showed a similar effect of maternal infection
    with toxoplasmosis. Preliminary, unpublished studies by Cohn and
    colleagues of the Public Health Institute in Berkeley, California, show
    an association between maternal serum levels of dichlorodiphenyl-
    trichloroethane and testicular cancer in male offspring later in life.
    The National Children's Study, currently under way, is designed to
    assess the effects of such environmental exposures during pregnancy and
    early childhood on many other aspects of health and disease later in
    life.
        In sum, the Barker Hypothesis, now 20 years old, has led to
    numerous productive lines of research which have relevance to many NIH
    Institutes, including the NICHD, NIDDK, NCI, NINDS, NHLBI, NIEHS, NINR,
    NIDA, NIAAA, NIAID and the NIMH.

                            WELLNESS AND PREVENTION

        Senator Harkin. I'm just curious. What Institutes would be
    the lead?
        Dr. Kington. Child health, I know, has funded. Aging has
    funded some, as well, because some of the early studies--the
    intriguing idea was that something happening in the uterus
    would be manifest in old age and some of the interesting
    studies focused on that element of this relationship.
        Senator Harkin. Do you have any idea about when we might be
    able to really get some body of evidence or something that we
    could rely on to say for prevention, we ought to be doing this
    and that pre-natal care and pregnant women ought to take
    certain factors into account?
        I don't know that we have enough to go on right now. I
    don't know. Do we?
        Dr. Kington. That's the point. I don't think we've resolved
    the scientific question enough to translate into a different
    way of doing what we're doing now, which is a lot of the things
    that you noted, good nutrition, all the prevention things that
    we know, pre-natal care, the social environment of pregnant
    women, all the things that we know are very important for
    having healthy babies.
        I don't think that the science is at a point where that
    would tell us to do something different or beyond what we know
    now as best practice. I think we're still ahead of the curve on
    that, but we're funding research and interesting ideas. It's
    been bandied about for a couple decades now and the evidence
    base was growing, not uniform support, but an evidence base and
    an interesting problem and question.
        Maybe Dr. Nabel might want to comment, as well.
        Dr. Nabel. Yes, I think the Barker Hypothesis raises in a
    broader term the concept of when should we begin prevention
    measures. I think that's probably one of the points you're
    getting to.
        From the cardiovascular and from the diabetes and obesity
    literature, we do know that the intrauterine environment makes
    a distinct difference in terms of predisposition toward
    subsequent diabetes and obesity in the newborn, but it also
    raises the fact that there's growing recognition among
    physicians, healthcare providers, that rather than waiting
    until middle age to focus on risk factor detection and
    prevention, we've got to shift much earlier and initially we
    shifted to the young adulthood but now we're increasingly more
    and more shifting to adolescence and childhood.
        In fact, the American Academy of Pediatrics has put out
    guideline recommendations for detection of cardiovascular risk
    factors, for example, in pediatric population.
        So there's growing recognition. Much of that recognition is
    built on the science base, that we're beginning to see,
    serendipitously, risk factors appearing in the pediatric
    office. When we go back and do natural history studies or
    observational studies then we can detect it on a scientific
    level.
        So yes, we know that these risk factors are appearing much
    earlier in life and that now is leading to action programs for
    detection and risk factor management.
        Senator Harkin. Very good. This is the last one, I promise,
    but I did want to get this in.
        Dr. Kington. You may ask as many questions as you like.

                       COMPARATIVE EFFECTIVENESS RESEARCH

        Senator Harkin. It has to do with comparative
    effectiveness. Dr. Nabel, this is probably to you.
        We provided $1.1 billion for comparative effectiveness in
    the Recovery Act. I have to admit, I did that and I have a lot
    of people asking about that. We put $400 million in there and
    that money is going to be used by NIH.
        We also created the Federal Coordinating Council for
    Comparative Effectiveness Research (CER), which will recommend
    priorities for this research and I understand you're a member
    of this Council.
        Again, can you tell me something about NIH's plans for the
    $400 million? What kinds of activities might fall into the
    category of comparative effectiveness research as far as NIH is
    concerned? What are you looking at and what are you going to
    use that money for?
        Dr. Nabel. Terrific. Well, thank you, Senator, for the
    question.
        As you know, the NIH has supported work that now fits the
    definition of comparative effectiveness research for many
    years, but we're delighted to have this additional money to
    again do things that we normally could not do or to jumpstart
    or accelerate other programs.
        Dr. Richard Hodes, the Director of the Aging Institute, and
    I co-direct the NIH Comparative Effectiveness Research
    Coordinating Committee. This is a committee that has brought
    together senior leadership, Institute Director leadership and
    deputy director leadership from across the agency to develop
    plans for that $400 million and again we're enormously
    grateful.
        We are looking at opportunities now that meet the
    definition of CER and would allow us to conduct research that
    again will either--something that we normally couldn't do or
    would jumpstart.
        We are looking at several possible mechanisms for
    supporting that research. One are payline expansions, so
    studies that Institutes have had to leave on the table because
    they simply did not have enough funds to initiate it. We're
    looking at the possibility of supplements that could accelerate
    enrollment in a trial or add an ancillary study or accelerate a
    trial in another way.
        We anticipate that over the summer we will have a broad
    number of Challenge Grants because in fact CER was one of the
    Challenge Grant topics. We anticipate we will have applications
    in CER, and we also anticipate there may be some GO
    applications that also meet the definition of CER.
        So we continue to meet on a regular basis. We are
    coordinating our work with the work of AHRQ and the Federal
    Coordinating Committee. We are working toward one common
    definition of CER for the department which we anticipate using
    and we are very cognizant of the fact that we want to make good
    use of this money. We want to get it right.
        We see this as a downpayment toward many CER activities
    that we would like to continue in the future.
        Senator Harkin. I wanted to get that on the record and
    thank you very much for your response on that.
        I have no further questions. Do you have anything else that
    any of you would like to bring up before we close this down?
        Well, let me just say thank you to all of you and to all of
    you in the row in the back and to all the Directors of the
    Institutes.
        Again, NIH is just one of our shining examples, I think, of
    good public policy and what we're using taxpayer dollars for
    and for all the years I've been privileged to associate with
    you, I just think you're doing an outstanding job at NIH, all
    of you.
        I thank you very much for your commitment to public service
    and to public health and to the research that we do at NIH and
    I always like to continue to say for the record that this is
    the National Institute of Health. It's not the National
    Institute of Basic Research. Basic research is important, but
    we always have to keep in mind we are looking at increasing the
    health of our people and of humankind in general. It's not just
    geared toward the American people, and so with all of that
    research we have to keep thinking about, what's that
    translational research, what's it going to translate into?
    Better health for people and I think NIH has done an
    outstanding job in that through all its years.
        So again, my thanks for your public service. I would again
    say, Dr. Kington, that I just repeat what I said earlier, I'm
    hopeful that this fall I will have healthcare reform behind us,
    maybe a little bit more time. It would be my intention and my
    desire and my intention to reprise again what we did a couple
    years ago. I'd love to have the Institute Directors down, two
    or three at a time, for some in-depth look at what the research
    is doing.

                         ADDITIONAL COMMITTEE QUESTIONS

        I think it's not only good for the record but I think it's
    good for us to know, me and the staff and the others who are
    charged with the responsibility of making some of these
    decisions to know exactly where we are and where some of the
    new research avenues that are going on in all these different
    Institutes. So I hope to be able to do that some time this
    fall.
        [The following questions were not asked at the hearing, but
    were submitted to the Department for response subsequent to the
    hearing:]
                   Questions Submitted by Senator Tom Harkin
                               pancreatic cancers
        Question. Dr. Niederhuber, one of the deadliest forms of cancer--
    pancreatic cancer--also seems to be one of lowest priorities of the
    National Cancer Institute (NCI). Pancreatic cancer research accounts
    for less than 2 percent of the Institute's budget. Last year, the
    subcommittee asked for a report on how resources will be used to
    address this problem. Would you tell us what, if anything, is being
    done to expand the research portfolio for this lethal form of cancer?
        Answer. NCI is committed to pursuing a broad research effort for
    pancreatic cancer. In 2001, NCI convened a Pancreatic Cancer Progress
    Review Group (PRG) to identify priority areas for research. Since that
    time, NCI's support for pancreatic cancer research has grown
    significantly. Based on the recommendations in the PRG report, NCI
    expanded its portfolio of pancreatic cancer research from $21.8 million
    in fiscal year 2001 to $87.3 million in fiscal year 2008. Part of this
    growth came about through planned actions and funding opportunities
    specific to pancreatic cancer, and part grew out of an increasingly
    larger pool of pancreatic cancer researchers successfully competing for
    general funding opportunities and unsolicited research grants.
        In the past 7 years, the number of investigators funded through the
    standard principal investigator-funding R01 awards has more than
    doubled, increasing from 34 to 93. The total number of research awards
    with a pancreatic cancer focus has more than tripled since fiscal year
    2000, increasing from 85 projects in fiscal year 2000 to 271 projects
    in fiscal year 2007.
        NCI has also increased the number of Specialized Program of
    Research Excellence (SPORE) grants with pancreatic cancer components,
    increasing the investment from one award in fiscal year 2000 to a total
    of six in fiscal year 2008. SPORE grants support specialized centers
    that promote interdisciplinary research, moving basic research findings
    from the laboratory to clinical settings while also bringing clinical
    findings back to the laboratory environment. SPORE investigators work
    collaboratively to plan, design, and implement research programs that
    may impact cancer prevention, detection, diagnosis, and treatment. Five
    of these SPORE grants were initially awarded shortly after the PRG
    meetings were held, with the sixth SPORE newly awarded in fiscal year
    2008.
        NCI continues to support pancreatic cancer research training awards
    for graduate students, postdoctoral trainees, clinical researchers, and
    junior faculty, as well as career transition and development awards for
    established investigators. In fiscal year 2005, an estimated 23
    distinct training projects were relevant to pancreatic cancer research
    and approximately $2.2 million was spent on these projects. In fiscal
    year 2006, an estimated 31 distinct training projects were relevant to
    pancreatic cancer research and approximately $2.7 million was spent on
    these projects. In fiscal year 2007, an estimated 36 distinct training
    projects were relevant to pancreatic cancer research and approximately
    $2.8 million was spent on these projects.
        NCI implemented a policy in fiscal year 2002 of increasing its
    payline (percentage of applications that are funded) for research that
    is related to pancreatic cancer. Initially, NCI's policy called for a
    50 percent higher payline for investigator-initiated R01 grant
    applications with 100 percent relevance to pancreatic cancer. Since
    fiscal year 2004, grant applications with 50 percent or greater
    pancreatic cancer relevance were given special consideration for
    exception funding.
        NCI has also developed pancreatic cancer-focused initiatives,
    including the Pilot Studies in Pancreatic Cancer and the Pancreatic
    Cancer Cohort Consortium. The Pilot Studies promote innovative
    multidisciplinary research to increase our understanding of pancreatic
    cancer biology, etiology, detection, prevention, and treatment. The
    Pancreatic Cancer Cohort Consortium is a group of investigators from 12
    prospective epidemiologic cohorts and 1 case-control study who conducts
    whole genome scans of common genetic variants in order to identify
    markers of susceptibility to pancreatic cancer. Pancreatic cancer
    studies have also been funded within the Mouse Models of Human Cancers
    Consortium, Novel Technologies for In Vivo Imaging, Cancer
    Nanotechnology Platform Partnerships, and the Early Detection Research
    Network.
        The Pancreatic Cancer Research Map is a Web-based tool developed
    for tracking pancreatic cancer research, clinical trials, and
    investigators. By providing a way to search the pancreatic research
    portfolio for funding opportunities, investigators, and developments in
    pancreatic research, the map facilitates and expedites collaborations
    and networking among researchers focuses on this disease.
        Recently, as part of the restructuring of the NCI Clinical Trials
    Enterprise, NCI formed the Gastrointestinal Intergroup. Pancreatic
    cancer is one of the gastrointestinal cancers that the group will be
    looking at as they harmonize an efficient, cost-effective, science-
    driven, and transparent process that will identify and promote the
    ``Best Science'' in gastrointestinal cancer clinical research by
    addressing the design and prioritization of large phase II studies and
    phase III trials in these cancers.
           progress in treatment and prevention of pancreatic cancer
        The number of therapeutic trials that can be conducted in any
    cancer type depends upon scientific opportunity, frequency of the
    disease, and its outcome. NCI has been able to test a large number of
    drugs intended to treat pancreatic cancer in small trials.
    Unfortunately, as you know, to date pancreatic cancer has proven to be
    unresponsive to most drugs and radiation therapies. Less than 20
    percent of patients with pancreatic cancer are candidates for surgery,
    because the disease is often detected in the late stages. Gemcitabine
    has been a standard treatment for patients with advanced and inoperable
    pancreatic cancer for a decade. New findings support use of the
    chemotherapy drug in the adjuvant setting, and patients who received
    the drug gemcitabine after surgery for pancreatic cancer lived 2 months
    longer than patients who had surgery alone. This study shows that this
    treatment improves a patient's survival and more than doubles the
    overall survival 5 years after treatment.
        Another study has shown that a new drug combination tested in mice
    may target the cells responsible for driving some pancreatic tumors.
    The combination of gemcitabine and the experimental drug tigatuzumab
    eliminated populations of cancer stem cells and reduced tumor growth in
    a mouse model of pancreatic cancer. The results provide a rationale for
    testing the promising combination in patients with this deadly disease.
    Tigatuzumab is also being tested in a phase II clinical trial with
    patients who have inoperable, untreated pancreatic cancer.
        Ultimately, only a better understanding of the genetics and biology
    of pancreatic cancer is likely to yield improved therapies. These
    fundamental breakthroughs are likely to be produced by basic and
    genetic research into the mechanisms of cancer risk, initiation,
    growth, and resistance, in which NCI is heavily invested. One such
    investment is PanScan, a project made up of 12 cohort and 8 case-
    control studies primarily supported by NCI. The goal of PanScan is to
    identify the genetic variants that increase the risk of developing
    pancreatic cancer and refine our understanding of the interactions of
    tobacco and other nongenetic risk factors with the genetic variants
    that increase pancreatic cancer risk.
        NCI anticipates that these studies will provide fundamental new
    insights into the genetic underpinnings of pancreatic cancer similar to
    the recent discoveries resulting from the genome-wide scans of prostate
    and breast cancers. These findings will inform further biological
    research that is likely to have clinical applications, including the
    detection of molecular targets for preventive, diagnostic, and
    therapeutic interventions. It is expected that the initial findings
    this study will be published later this year.
        NCI is also involved in the Pancreatic Cancer Genetic Epidemiology
    (PACGENE) Consortium which was developed to identify susceptibility
    genes in familial pancreatic cancer. The Consortium consists of seven
    data collection centers, a statistical genetics core, and a pathology/
    archival genotyping core. PACGENE recruits people with two or more
    affected blood relatives found through incident pancreatic
    adenocarcinoma cases, physician referrals, as well as Internet
    recruitment. Accrual to a database containing core clinical,
    demographic, lifestyle and family history information from
    questionnaires is ongoing, along with biospecimen collection. The
    shared goals and methodologies of data collection of this Consortium
    will facilitate and accelerate our understanding of the genetic basis
    of pancreatic cancer.
        In addition to genetic research, NCI is also supporting pancreatic
    cancer research that utilizes nanotechnology. Cancer Nanotechnology
    Platform Partnerships, a component of NCI's Alliance for Nanotechnology
    in Cancer, are developing technologies for new products in such areas
    as molecular imaging and early detection. One partnership is studying
    the use of nano particles in the diagnosis and therapy of pancreatic
    cancer, and developing and testing nano particles that will deliver
    imaging and therapeutic agents to pancreatic tumors.
                                   prevention
        There are presently no effective ways to detect early signs of
    pancreatic cancer. One way to discover susceptibility genes for an
    inherited disease is to analyze DNA from large families with many
    affected members. But this strategy does not work with inherited forms
    of pancreatic cancer, because the disease is so deadly that there are
    very few large families with adequate numbers of samples.
        Researchers at the Johns Hopkins Kimmel Cancer Center have shown
    for the first time that sequencing the genes in both the normal and the
    cancer cells of a single patient can reveal genes that are altered in
    both types of cells. Some of these changes can help identify
    susceptibility genes.
        This strategy offers a new way to find hereditary susceptibility
    genes, and in the future, these genes could be part of a panel used to
    evaluate patients with familial pancreatic cancer. A test for
    predisposing mutations could help identify people at high risk of the
    disease who could be monitored for precancerous changes, enrolled in
    screening programs and potentially prevent them from getting pancreatic
    cancer.
        Question. In addition to pancreatic cancer, would you tell us how
    NCI plans to attack some the other deadly cancers--ones where survival
    rates remain low?
        Answer. In terms of other deadly cancers, the following are the
    ones with the lowest percentage for 5-year relative survival rate (30
    percent or lower).
                                 ovarian cancer
        The high-mortality rate stems from an overall lack of early
    symptoms or screening methods for the disease. As a result, most
    ovarian cancer patients are diagnosed with advanced stage disease. For
    fiscal year 2009, NCI is funding 5 SPORE program grants, and the
    relatively low incidence of this disease, as well as the team concept
    of the SPORE program, has resulted in a number of Inter-SPORE
    activities aimed at developing much needed early detection, screening,
    prevention, and therapeutic tools for ovarian cancer. These
    supplemental activities are being performed in collaboration with a
    number of other NCI programs, including Avon Progress for Patients
    Partnership, the Cancer Genetics Network, the Early Detection Research
    Network, the Division of Cancer Prevention's Prostate, Lung, Colon, and
    Ovarian Cancer (PLCO) Screening Trial and the NCI Intramural Program.
        The Cancer Genome Atlas (TCGA) is assessing the feasibility of
    systematically identifying the major genomic changes involved in cancer
    using state-of-the-art genomic analysis technologies. Ovarian cancer is
    one of the first cancer types to be studied in the TCGA pilot phase.
    Early results are revealing genetic changes that could be used to
    identify those women who may be at risk for developing ovarian cancer,
    as well as pointing to markers for early detection of the disease when
    there is a better potential for successful therapy.
        NCI's Cancer Nanotechnology Platform Partnerships are developing
    technologies for several key areas including studies focused on
    developing multifunctional nanoparticles that can deliver light-
    activated anticancer compounds specifically to ovarian cancer cells
    through a partnership at the Massachusetts General Hospital.
        The New Drug Combination for Ovarian and Primary Peritoneal Cancers
    clinical trial is testing the combination of cisplatin, a drug
    containing platinum, and flavopiridol, which blocks the activity of
    proteins that help cancer cells grow and spread, in women with ovarian
    or peritoneal cancer resistant to platinum-based chemotherapy.
    Flavopiridol can increase the platinum concentrations in cells when
    administered with cisplatin, and researchers believe that this may lead
    to a reversal of platinum resistance.
        The National Ovarian Cancer Early Detection Program.--Screening and
    Genetic Study is determining effective screening and genetic testing
    methods to identify women at increased risk of ovarian cancer. The
    study is also designed to develop markers for early detection and novel
    therapies.
                           liver and bile duct cancer
        Primary liver and bile duct cancers are the fifth most common cause
    of cancer death in men and the ninth most common cause of cancer death
    in women. More than 90 percent of all cases occur in men and women age
    45 or older. Liver cancer is closely associated with hepatitis virus
    infections, especially hepatitis B.
        A clinical trial, Hepatic Arterial Infusion of Melphalan with
    Hepatic Perfusion in Treating Patients with Unresectable Liver Cancer,
    is evaluating the effectiveness of hepatic arterial infusion
    (delivering chemotherapy directly to the liver) of the drug melphalan
    combined with hepatic perfusion (delivering chemotherapy to a blood
    vessel) in patients with liver cancer
        The Etiology, Prevention, and Treatment of Hepatocellular Carcinoma
    program supports research on the etiology of liver cancer, development
    of animal models, novel prevention approaches, identification of
    reliable predictors of disease progression, and ways to minimize the
    morbidity and mortality associated with this disease.
        The Tumor Microenvironment Network is exploring the role of the
    microenvironment, the cells and blood vessels that feed a tumor cell,
    in tumor initiation and progression. Network investigators are
    examining the role of inflammation and the microenvironment in the
    development of liver cancer.
                               esophageal cancer
        The Prevention Agents Program provides scientific and
    administrative oversight for chemoprevention agent development from
    preclinical research to early Phase I studies. The program is currently
    supporting research on several agents for potential chemoprevention of
    esophageal cancer.
        The interdisciplinary scientists of the Network for Translational
    Research: Optical Imaging is accelerating translational research in
    optical imaging and/or spectroscopy. Current efforts include the
    development of techniques to identify molecular markers for detecting
    esophageal neoplasia and understanding basic disease mechanisms.
        The Cancer Prevention Research Small Grant Program is supporting
    several research projects focused on esophageal cancer, including
    studies on esophageal cancer biomarkers, a mouse model of esophageal
    adenocarcinoma, and the molecular mechanisms involved in the
    development of Barrett esophagus. The latter is a condition in which
    the cells lining the lower part of the esophagus have changed or been
    replaced with abnormal cells that could lead to cancer of the
    esophagus. The backing up of stomach contents (reflux) may irritate the
    esophagus and, over time, cause Barrett esophagus.
                                  lung cancer
        Lung cancer is the second most common cancer and the most common
    cause of cancer-related death in both men and women in the United
    States.
        Seven lung cancer-specific Specialized Programs of Research
    Excellence (SPOREs) are promoting interdisciplinary research and moving
    basic research results from the laboratory to the clinical setting.
        TCGA is assessing the feasibility of systematically identifying the
    major genomic changes involved in cancer using state-of-the-art genomic
    analysis technologies. Lung cancer is one of the first cancer types to
    be studied in the TCGA pilot phase.
        PLCO Cancer Screening Trial is determining whether certain cancer
    screening tests reduce deaths from prostate, lung, colorectal, and
    ovarian cancers.
        NCI's Lung Cancer Program supports research on early detection and
    treatment. The Lung Cancer Biomarkers Group is developing sets of
    specimens that can be used to test biomarkers for the early detection
    or diagnosis of lung cancer.
        The Mouse Models of Human Cancers Consortium is developing models
    of lung cancer to aid in our understanding of lung tumor biology and to
    facilitate the development and testing of novel therapeutic approaches
    and methods for early diagnosis.
                                 stomach cancer
        The overall incidence of stomach cancer in the United States has
    declined in the past 75 years. Five gastrointestinal cancer-specific
    SPOREs are moving results from the laboratory to the clinical setting.
        The Tumor Microenvironment Network is exploring the role of the
    microenvironment, the cells and blood vessels that feed a tumor cell,
    in tumor initiation and progression. Network investigators are studying
    the role of inflammation and the tumor microenvironment in stomach
    cancer.
        NCI's Infections and Immunoepidemiology Branch conducts high-impact
    epidemiologic research on infectious agents and cancer. Researchers are
    investigating why stomach cancer risk is low in Africa, despite high
    rates of Helicobacter pylori infection, as well as genetic factors
    associated with stomach cancer risk.
        The Community Clinical Oncology Program (CCOP) and the Minority-
    Based Community Clinical Oncology Program (MB-CCOP) are comprehensive
    clinical trial mechanisms that disseminate the latest cancer prevention
    and treatment research findings to the community. Several CCOP and MB-
    CCOP groups currently participate in stomach cancer clinical trials.
                                    myeloma
        Myeloma, also known as multiple myeloma or plasma cell myeloma is
    the second most common blood cancer in the United States. The myeloma-
    specific SPORE is moving results from the laboratory to the clinical
    setting. This program is studying novel myeloma therapies and
    identifying new markers of this disease.
        The Multiple Myeloma Prevention Study is evaluating the use of
    nonsteroidal anti-inflammatory drugs to modulate biomarkers associated
    with monoclonal gammopathy of undetermined significance, a condition
    that sometimes precedes the development of myeloma.
        The Quick-trials for Novel Cancer Therapies and Prevention.--
    Exploratory Grants program expedites clinical translation of basic
    research discoveries in cancer biology through the development of novel
    anti-cancer drugs, diagnostic tools, treatments, and prevention
    strategies. This program currently supports two projects focused on
    immunotherapy and on improving the effectiveness of stem cell
    transplants in myeloma patients.
        Question. Is NCI considering a plan to specifically and
    comprehensively address these lethal cancers?
        Answer. Nearly half of the over 500,000 expected cancer deaths this
    year will be caused by 8 forms of cancer with 5-year relative survival
    rates of less than 50 percent-lung, liver, pancreatic, ovarian, brain,
    stomach, esophagus cancers and myeloma-and most of these cancers
    disproportionately affect minorities and under-served subgroups in the
    United States. These cancers are often difficult to diagnose early.
    Cancers of high lethality pose a significant research challenge. These
    aggressive tumors are usually diagnosed late in their disease course,
    making the study of early disease progression and promotion, as well as
    the impact of genetic and environmental exposures, especially
    difficult.
        NCI proposes to increase research on highly lethal cancers by
    expanding its investment into molecular epidemiological approaches such
    as the Cohort Consortium-of which the Pancreatic Cancer Cohort
    Consortium (PanScan) is one component--TCGA and genome-wide association
    studies to accelerate a fuller understanding of cancer causation and
    provide scientific direction of early detection, prevention and
    targeted therapeutic strategies. Molecular interrogation will generate
    data that can be used to evaluate profiles across the disease spectrum
    as well as among ethnic and racial populations.
                                nih medline plus
        Question. This subcommittee has long supported increased efforts by
    the NIH to provide the public important health information based on the
    results of the medical research their taxpayer monies support. At my
    urging, the NLM has increased its commitment to boost the distribution
    of the NIH MedlinePlus magazine. It is my understanding that a new
    bilingual version of the magazine, NIH MedlinePlus Salud, has been
    tested. What steps can be taken to substantially increase the public's
    access to these publications by getting them to all physician offices,
    community health clinics, and libraries?
        Answer. Distribution of the magazines has increased from 50,000
    copies of each issue in 2006 to over 500,000 copies of the English and
    Spanish versions in 2008. We estimate that the magazines now enjoy a
    readership of approximately 5 million nationwide. In February 2009, NLM
    created improved online versions of both magazines, which makes it easy
    for people to find, use, and email individual articles from the
    complete set of issues.
        To increase distribution of the magazines still further, NLM, other
    NIH Institutes and Centers, and the Friends of the National Library of
    Medicine are forming partnerships with other Government agencies and
    private organizations which have an interest in supporting and enabling
    distribution of high-quality health information to their respective
    audiences. For example, the Peripheral Arterial Disease (PAD) Coalition
    supported the distribution of an additional 250,000 copies of one 2008
    issue. In addition, the National Alliance for Hispanic Health is
    helping to support the production and distribution of NIH MedlinePlus
    Salud, which is an English/Spanish version. The pilot issue featured
    Cuban American journalist Cristina Saralegui, who is well known for her
    Univision talk show, The Cristina Show, as well as her work on behalf
    of health and wellness causes.
        Question. Is this something that could be done with stimulus
    funding?
        Answer. NIH is extremely grateful for the opportunities and funding
    provided in the American Recovery and Reinvestment Act of 2009 (ARRA)
    to preserve and create jobs and promote economic recovery by spurring
    technological advances in science and health. NLM is investigating how
    it may best use ARRA dollars to support the spirit of the Recovery Act,
    including increasing the distribution of the NIH MedlinePlus and NIH
    MedlinePlus Salud magazines.
                             interstitial cystitis
        Question. According to NIH's recently revised methods for
    calculating support levels for various disease research areas, the
    amount dedicated to interstitial cystitis (IC) is less than half of
    what NIH previously believed it to be. (NIH originally estimated the
    fiscal year 2007 funding for IC research to be $23 million; new
    calculations show that the actual amount was just $10 million.) This is
    disappointing, given that this condition afflicts more than 8 million
    Americans.
        What are the agency's plans to further basic and clinical research
    in this area?
        Answer. NIH's shift to a new and more consistent process--requested
    by the Congress--to report on certain diseases and conditions through
    the Research, Condition, and Disease Categorization (RCDC) system, has
    indeed led to changes in reported funding levels for a variety of
    conditions, including IC. There are a number of reasons for these
    differences, including precise ``definitions'' for some disease
    reporting categories under the new system. More information is
    available on our RCDC Web site, at http://report.nih.gov/rcdc/reasons/.
    We began using RCDC to report actual funding levels in fiscal year
    2008. To ensure transparency during the transition to RCDC, the NIH
    disease funding table provides a side-by-side comparison of the actual
    fiscal year 2007 levels produced using the prior method and the levels
    that would have resulted if RCDC had been implemented that year--
    thereby illustrating the effect of the RCDC methodology and clarifying
    the changes between fiscal year 2007 and fiscal year 2008 resulting
    from use of this new process. For example, while the actual amount of
    funding reported for IC in fiscal year 2007 was $23 million, the RCDC
    analysis of the fiscal year 2007 portfolio reflected annual funding
    support of $10 million. The actual funding level reported for fiscal
    year 2008 of $10 million is comparable with the amount identified for
    fiscal year 2007 using the new RCDC methodology. While the impact of
    this change has in some instances resulted in significant one-time
    adjustments, it is important to note that they do not reflect a change
    in the NIH's commitment to research on IC and other conditions, and
    will ultimately result in more accurate, consistent reporting across
    NIH. Research that can lead to improved detection, treatment, or cure
    for IC remains a high priority for NIH.
                                     ______

                Questions Submitted by Senator Daniel K. Inouye
                                pharmacy program
        Question. Dr. Sidney McNairy, Director of the Division of Research
    Infrastructure, met with the University of Hawaii at Hilo faculty and
    administrative staff in December 2008. What are we doing or should we
    be doing to help the new University of Hawaii at Hilo's new pharmacy
    program meet the objectives set by Dr. McNairy's site visit?
        Answer. One of the objectives set forth during Dr. McNairy's visit
    was to facilitate an expanded role of the University of Hawaii at Hilo
    in the Institutional Development Award (IDeA) Program's IDeA Networks
    of Biomedical Research Excellence (INBRE) initiative within National
    Center for Research Resources (NCRR), a component of the National
    Institutes of Health (NIH). The long-term objective is to facilitate
    the development of the research infrastructure in the School of
    Pharmacy at Hilo and foster collaboration with the Manoa campus.
        Subsequent to this visit, Dr. McNairy and his staff set up several
    teleconferences with the Dean of the School of Medicine at the Manoa
    campus and the Dean of the School of Pharmacy at Hilo to discuss plans
    for the development of a joint application to compete for support via
    the INBRE initiative. As a result, these institutions are developing an
    application that includes core research facilities and instrumentation
    at the Hilo campus; support for research projects for junior faculty
    investigators at Hilo aimed at transitioning them to independent
    research support; and alterations and renovations at the Hilo campus.
    The Hawaii INBRE application will also include collaborations with
    several community colleges and 4-year institutions. Interactions with
    these latter institutions will provide the School of Pharmacy with an
    expanded pool of potential candidates for entry into the pharmacy
    program.
        Question. What is being done to anchor these activities and help
    assure success?
        Answer. NCRR staff participates in teleconferences with the
    Principal Investigator of the proposed Hawaii INBRE to review the
    details of the funding opportunity announcement (PAR-08-150), answer
    questions, and provide programmatic advice during the development of
    the application. The institutions are working toward the submission of
    this application in fiscal year 2009.
        Question. Many initiatives and programs that have recently been
    launched by the National Cancer Institute (NCI) appear to be based on
    mechanisms that utilize center-based models. Large awards or
    cooperative agreements are made to large, well-established institutions
    and individual researchers. One criticism of such a model has been that
    it detracts from an already depleted investigator-initiated pool of
    grants for funding cancer and biomedical research. What steps is the
    NCI taking to ensure that adequate resources in the form of
    investigator-initiated research project grants continue to be made
    available to not only individual investigators but to young and/or new
    investigators?
        Answer. The allocation to investigator-initiated research continues
    to represent the largest component of the NCI budget. That is a strong
    demonstration of the commitment the Institute has to investigator-
    initiated research. Equally strong is the Institute's commitment to
    first-time investigators. NCI allocated $74 million to pay new
    competing grant applications from first time investigators in fiscal
    year 2007 and raised that to $82 million in fiscal year 2008. Research
    Project Grants (RPGs) represent 44 percent of NCI's fiscal year 2009
    budget. NCI intends to increase the number of first-time investigators
    in fiscal year 2009 using additional American Recovery and Reinvestment
    Act funds to support the first 2 years of their research project and
    then continuing their support in years 3-5 with appropriated funds.
                  innovative approaches and novice researchers
        Question. What efforts are currently underway to stimulate and
    support new, novel, and innovative approaches to the detection,
    treatment, and diagnosis of cancer?
        Answer. NIH supports innovative approaches to the detection,
    treatment, and diagnosis of cancer. NCI established the Innovative
    Molecular Analysis Technologies (IMAT) program to support the
    development, technical maturation, and dissemination of novel and
    potentially transformative next-generation technologies through an
    approach of balanced, but targeted innovation. The IMAT program
    utilizes a variety of investigator-initiated research project grant
    mechanisms while retaining a strong commitment to diversity and to the
    training of scientists and clinicians in cross-cutting, research-
    enabling disciplines.
        Nanotechnology represents a large number of advanced technologies
    that promise to change all aspects of 21st century medicine, especially
    cancer medicine. This is an area that brings scientists from physics,
    chemistry, mathematics, and engineering together with cancer biologists
    and oncologists to develop new cancer interventions. NCI launched the
    Alliance for Nanotechnology for Cancer program in 2004 to capitalize on
    these technologies. These centers are developing and translating novel
    nanotechnology-enabled diagnostic, imaging, and therapeutic platforms
    into clinical practice--which is required to capitalize on our prior
    investments in the molecular sciences. The original program produced
    several nano platforms that are currently in preclinical evaluation
    with a few already in clinical trials. The Alliance is a magnet for
    young creative scientists. Trained in the molecular sciences,
    bioinformatics, and physics, these centers have attracted the best--
    bringing Nobel Prize winners together with scientists that are early in
    their careers. Together they are creating new training and research
    opportunities that are driving this emerging field.
        Question. Through what mechanisms are such programs funded, and is
    there a percentage or grant category designated to support the
    development of novice researchers?
        Answer. NCI allocated 17 percent of the competing RPG budget to
    select grant applications that were identified as filling gaps in the
    research portfolio or representing novel approaches to research
    problems. We often refer to the grants funded with that pool as
    ``exceptions'' to the regular payline. One-third of that exception pool
    was allocated to supporting first-time investigators. Those exceptions
    are used across the portfolio, including in the areas of detection,
    treatment, and diagnosis.
        The NCI Alliance for Nanotechnology in Cancer program, for example,
    utilizes several mechanisms, including the U54 center mechanism, R25
    training center mechanism, K99/R00 fellowships mechanism, and U01
    investigator-initiated research project mechanism. Based on comparison
    of landscape before and after the initial program, there is a clear
    trend of increased interest in cancer nanotechnology training as NIH
    fellowship applications supported by the original program (F32/F33)
    increased significantly since the program began. Postdoctoral students
    are the largest group participating in the alliance and, in fact,
    dominate the annual meeting where their research is presented. A
    similar increasing trend for NCI is seen in both individual training
    awards (K99) and institutional training awards (T32, R25). When the
    Alliance for Nanotechnology in Cancer began, the Institute supported a
    total of 4 individual-initiated grants in the field; that number has
    increased to 48 (excluding Alliance awardees) during the 5 years that
    the Alliance has been in place, and the Alliance shows signs of further
    expansion as more young people enter this new field.
                              military researchers
        Question. The National Institute of Nursing Research (NINR) lists
    (1) Integrating Biological and Behavioral Science for Better Health;
    (2) Adopting, Adapting and Generating New Technologies for Better
    Health Care; (3) Improving Methods for Future Scientific Discoveries;
    and (4) Developing Scientists for Today and Tomorrow as its 2006-2010
    Strategic Goals, with a research emphasis on Promoting Health and
    Preventing Disease, Improving Quality of Life, Eliminating Health
    Disparities, and Setting Directions for End-of-Life Research.
    Historically, military nurse researchers have been unable to compete
    for funds due to the uniqueness of the population they serve.
    Considering the ongoing status of conflict in the Middle East and other
    countries, what efforts are being taken to allow military nurse
    researchers to actively compete for these funds?
        Answer. The NINR strongly encourages all scientists to apply for
    funding within the NINR areas of research emphasis. There are no
    funding exclusions based on military status. Currently, the NINR is
    sponsoring a research initiative entitled, ``Improving Quality of Life
    of Patients and Family Following a War-Related Traumatic Injury'' to
    develop and test personalized interventions to prevent complications in
    persons with war-related traumatic injuries during the post
    hospitalization transition period, with the ultimate goal of improving
    the health and quality of life of individuals and families following a
    war-related traumatic injury. NINR is actively involved in the
    collaboration between the NIH and the Center for Neuroscience and
    Regenerative Medicine at the Uniformed Services University of the
    Health Sciences (USHUS) to answer difficult research questions and
    improve medical care for service members with brain injuries and Post-
    Traumatic Stress Disorder. Through this collaboration, there are
    valuable training opportunities for nurse scientists. Other Federal
    partners collaborating in this effort are the Defense Centers of
    Excellence for Psychological Health and Traumatic Brain Injury, Army
    Medical Research Command labs, Navy labs, and the Walter Reed National
    Military Medical Center.
        NINR also has a long-standing relationship with the TriService
    Nursing Research Program at USHUS to facilitate collaboration and to
    consult on matters relevant to military nursing research. One of the
    members of the National Advisory Council for Nursing Research (NACNR)
    is Capt. Maggie Richard, Ph.D., MSN, NC, USN. Captain Richard is the
    director of the Human Research Protection Program in the Bureau of
    Medicine and Surgery, the Department of the Navy. She has served more
    than 20 years in the Navy Nurse Corps, and is the former head of the
    Nursing Research Service at the Bethesda National Naval Medical Center.
    As a member of the NACNR, Captain Richard provides the second level of
    review of grant applications, and recommends to the Institute Director
    which applications should be approved and considered for funding.
        NINR remains dedicated to supporting clinical and basis research to
    help improve the health of the Nation, including members of the
    military service.
                                  nci and cis
        Question. While the NCI intends to retain the information service
    arm of the Cancer Information Service (CIS) (i.e., 1-800-4CANCER
    service, the Internet, and instant messaging), NCI leadership has
    decided not to continue funding the CIS Partnership Program beyond the
    current contract period, ending January 15, 2010. What is NCI's plan
    for responding to the cancer information, training and technical
    assistance needs of remote, medically underserved communities and the
    organizations that serve them, such as those located in Hawaii and the
    U.S.-Associated Pacific Island jurisdictions?
        Answer. Rather than renew the Partnership Program, we have
    reassessed how NCI can most effectively and efficiently disseminate
    important cancer information, and engage communities in order to
    realize an impact in the lives of those we serve. NCI will actively
    align its community outreach with its community-based research programs
    and build capacity in communities for the effective delivery of cancer
    information to their members. Building on the success of projects such
    as the Imi Hale-Native Hawaiian Cancer Network and the American Samoa
    Community Cancer Network, as well as the partnership between the
    University of Hawaii and the University of Guam, NCI will support
    community-based research programs that will build capacity to meet the
    needs of the underserved populations.
        Beginning in January 2010, NCI will augment community-based
    research projects to include a community outreach structure that will
    specifically employ community outreach staff. While it is expected that
    these staff members will service the outreach needs for those funded
    projects, NCI is also expecting them to perform activities to address a
    broader area of needs identified by NCI. The funded projects that will
    initiate this new model of outreach include the Community Networks
    Program-II (CNP-II), the Minority Institution/Cancer Center Partnership
    (MI/CCP), and the NCI Community Cancer Center's Program (NCCCP),
    representing a total of 66 sites initially.
        The establishment of a coordinated outreach network that works
    within established NCI-supported research programs will provide
    national geographic coverage for outreach to all populations. The
    proposed Community Outreach Core within the CNP-II concept will employ
    health education/community outreach staff to foster activities
    supporting the community and community partners. A similar approach
    within the MI/CCP and NCCCP would further augment and reinforce this
    national outreach network. Within the MI/CCP, for example, all
    partnerships are encouraged to have outreach programs and activities
    linking scientific discoveries and implementation of scientific
    breakthroughs in high-risk populations, and some partnerships are also
    increasing enrollment of racial/ethnic minorities in clinical trials.
    The outreach and partnership components of the CIS partnerships can be
    successfully integrated and absorbed within the existing community
    outreach cores of NCI funded research initiatives to enhance and
    strengthen NCI's ability to educate and engage communities in
    addressing cancer health disparities within diverse, high-risk
    populations. NCI will also examine the feasibility of expanding this
    model to other NCI-funded programs.
        NCI already has an outreach and dissemination infrastructure within
    its Office of Communications and Education that will provide these
    grantees the necessary technical assistance for communication,
    dissemination, and outreach. This infrastructure supports the current
    CIS Partnership Program. They are prepared to provide this national
    outreach network guidance in the use of best practices, the development
    of shared resources and tools, and the provision of training and
    technical assistance to community outreach coordinators in
    comprehensive cancer control and the delivery of evidence-based
    outreach activities.
        In addition to the establishment of this national outreach network
    through NCI-funded programs, NCI is already in the process of planning
    a concept for dissemination, community outreach, and communication.
    This process, which has been described in responses to previous
    inquiries on this matter, utilizes a public health planning approach
    which examines the scientific evidence across areas of cancer control
    and engages the community throughout the process in feedback loops, and
    will ultimately yield a concept that aims to reduce the impact of
    cancer in the most vulnerable communities. Greater details on the
    planning process for this can be provided upon request.
                                     ______

                    Question Submitted by Senator Herb Kohl
                increasing funding and greater number of awards
        Question. Dr. Kington, I was pleased to see that funding sources
    for the National Institutes of Health Clinical and Translational
    Science Awards (CTSA) were increased this year, through both the fiscal
    year 2009 omnibus appropriations bill and the American Reinvestment and
    Recovery Act. I am aware that several institutions applying for awards
    this year, including applicants in my home State of Wisconsin, have
    received ``outstanding'' application ratings. Will this increase in
    funding allow for a greater number of awards to be distributed?
        Answer. The funding provided in the Omnibus Appropriations Act,
    2009, will support new CTSAs in fiscal year 2009 as the program moves
    closer to a goal of 60 CTSAs.
        The American Recovery and Reinvestment Act (ARRA) funding is being
    used to allow existing CTSAs to compete for resources to supplement
    their current activity, plus support other researchers who may apply to
    leverage current CTSA activities. However, since normal CTSA funding is
    for 5 years and ARRA funds are limited to 2 years the funding is not
    able to support new awards.
                                     ______

                Questions Submitted by Senator Mary L. Landrieu
    small business innovation research (sbir) and small business technology
                            transfer (sttr) programs
        Question. When the American Recovery and Reinvestment Act (ARRA)
    passed in February, it contained a short sentence that directly hurt
    small businesses by exempting two important small business programs.
    The provision, which provided $8.2 billion to the National Institutes
    of Health's (NIH), exempted the NIH from the statutory requirement that
    2.8 percent of extramural research and development (R&D) money be used
    for the Small Business Innovation Research (SBIR) and the Small
    Business Technology Transfer (STTR) programs. As the chair of the
    Senate Small Business Committee, and as a member of this appropriations
    subcommittee, I was never consulted or notified about the exemption
    language which was added in conference. My staff has been told by NIH
    officials and others that NIH directly requested the exemption. As a
    result of the exemption, the NIH is not required to award up to $200
    million from the ARRA funds to small businesses for research and
    development. This exemption went directly counter to the principles and
    goals of ARRA. The recovery effort was supposed to be about creating
    high-quality jobs, spurring innovation, and giving a boost to
    businesses across the board. Instead, this language singled out small
    businesses and slashed the relatively tiny amount they are normally
    guaranteed. I have several questions for Dr. Kington regarding NIH's
    request and the exemption: Specifically, who at the NIH requested that
    ARRA be exempt from funding the SBIR and STTR programs? Was this
    request first cleared through you?
        Answer. NIH was concerned about the decreasing number of SBIR
    applications. We had seen nearly a 40 percent decrease in applications
    during the fiscal years 2004 through 2008. Although the NIH is not
    required by this law to provide a set amount of ARRA funds toward the
    SBIR/STTR programs, it is important to note that small businesses are
    able to apply for and will receive funds. NIH remains committed to the
    small business community and has been encouraging small businesses to
    apply for stimulus funds through various funding opportunity
    announcements that have been released.
        Question. From your experience at NIH, would you agree that the
    SBIR and STTR programs play a vital role in NIH's extramural R&D
    because of the high levels of innovation that come out of these two
    programs?
        Answer. NIH has supported and continues to support small business
    and efforts to bring innovations from biomedical research to the
    taxpayer. NIH research is driving a vibrant community of American small
    businesses and entrepreneurs in the health enterprise. NIH-funded
    research leads to patents and spin-off companies across the Nation.
    Through the SBIR and STTR programs, the NIH helps nurture entrepreneurs
    as they bring products to the international market that improve health
    and well-being. Small businesses supported by NIH grants help maintain
    American economic leadership.
        For example, Kinetic Muscles, a small business in Arizona, has
    developed the Hand Mentor ProT, which is a device designed for
    neurological rehabilitation of the hand and wrist for people who have
    suffered strokes or other brain injuries. In partnership with their
    exclusive distributor, Columbia Scientific, the Hand Mentor ProT is now
    being used in select HealthSouth rehabilitation hospitals.
        Biopsy Sciences of Florida has developed the Bio-SealT and recently
    sold the technology to Angiotech Pharmaceutics, Inc. (a global
    specialty pharmaceutical and medical device company). This novel
    technology was designed to reduce the incidence of postoperative
    pneumothorax (collapsed lung) in patients who undergo lung biopsy
    procedures. The technology involves placement of an expanding hydrogel
    plug along the biopsy needle track during the procedure, closing off
    the track to subsequent influx of air into the chest during respiration
    after the biopsy needle is withdrawn. The seal is airtight and the plug
    is absorbed into the body after healing of the puncture site has
    occurred.
        These are only a few examples of the high level of innovation and
    the many products that have been developed with NIH SBIR/STTR funding.
        Question. From your experience at NIH, would you agree that small
    businesses doing extramural R&D for the NIH have a proven record of
    creating jobs?
        Answer. Small businesses have long been the engine of U.S. economic
    growth, generating a significant proportion of new jobs annually, and
    we believe NIH's SBIR/STTR programs assist with the creation of high-
    quality jobs. NIH has invested in excess of $5 billion in more than
    19,000 projects to over 5,000 small businesses. Past studies of the
    SBIR program conducted by the NIH and the National Research Council
    (NRC) have shown small businesses are seen as sources of economic
    vitality and are especially important as a source of new employment.
        Question. Could you please provide, in detail, the steps NIH is
    taking to make sure small businesses receive an adequate share of ARRA
    funds?
        Answer. NIH has taken several steps to ensure small businesses
    receive an adequate share of the ARRA funds appropriated to NIH.
    Outreach efforts have been stepped up to alert small companies of ARRA
    opportunities. In the last few months, eight SBIR/STTR presentations
    have been given throughout the country at life science or SBIR/STTR
    conferences in New Jersey, Indiana, Kentucky, New York, Maryland,
    Washington, DC, and California. NIH's 11th Annual SBIR/STTR Conference
    was held at the end of June 2009 in Omaha, Nebraska, and with
    attendance typically in the hundreds, this was another excellent
    opportunity to disseminate information about specifically targeted ARRA
    opportunities to this small business audience.
        During the past few months, NIH has strongly encouraged small
    businesses to apply for several of its funding opportunity
    announcements (FOAs) that were supported by ARRA, including:
      --The NIH Challenge Grants in Health and Science Research or
            ``Challenge Grants'' http://grants.nih.gov/grants/guide/rfa-
            files/RFA-OD-09-003.html
        This opportunity focuses on specific knowledge gaps, new
    technologies, data generation, or research methods that would benefit
    from an influx of funds to quickly advance the area in significant
    ways.
      --Research and Research Infrastructure ``Grand Opportunities'' or
            ``GO Grants'' http://grants.nih.gov/grants/guide/rfa-files/RFA-
            OD-09-004.html
        This opportunity focuses on developing and implementing critical
    research innovations to advance their research enterprises, stimulate
    future growth and investments, and advance public health and health
    care delivery.
        In June, NIH released two additional announcements that explicitly
    targeted the private sector commercial research community. These
    included:
      --Recovery Act Limited Competition: Biomedical Research, Development,
            and Growth to Spur the Acceleration of New Technologies (BRDG-
            SPAN) Pilot Program, http://grants.nih.gov/grants/guide/rfa-
            files/RFA-OD-09-008.html
        This FOA is a pilot program that focuses on the funding gap between
    promising research and development and transitioning to the market by
    contributing to the critical funding needed to pursue the next
    appropriate milestone(s) toward ultimate commercialization. Any U.S.-
    owned, for-profit enterprise/commercial organization is encouraged to
    apply for this funding. Please note that applications received under
    this FOA may be given funding priority if the applicant is associated
    with an enterprise or commercial organization that is of small size
    and/or has limited resources.
      --Recovery Act Limited Competition: Small Business Catalyst Awards
            for Accelerating Innovative Research, http://grants.nih.gov/
            grants/guide/rfa-files/RFA-OD-09-009.html
        This opportunity specifically targets the SBIR research community
    and focuses on accelerating innovation through high- risk, high-reward
    research and development that has commercial potential and is relevant
    to the NIH mission. It seeks to encourage fresh research perspectives
    and approaches and focuses on early-stage ideas that promise to lead to
    major leaps forward rather than incremental improvements of existing
    technologies. Only U.S. small business concerns are eligible to submit
    Phase I SBIR applications, and first-time applicants to NIH may receive
    funding priority.
        In addition to releasing these funding opportunity announcements,
    the pay-lines at various NIH Institutes and Centers have been extended
    to reach more meritorious research grants, including those submitted by
    small businesses. Finally, in March 2009, NIH offered three
    administrative supplement and competitive revision opportunities for
    those with active research project grants (including SBIR and STTR).
    The supplements provided additional funding to accelerate the tempo of
    scientific research on active grants. Revision awards support a
    significant expansion of the scope or research protocol of approved and
    funded projects. Administrative supplements were also offered to
    provide summer research experiences for students and science educators.
    SBIR and STTR projects successfully competed. At this time, over 20
    SBIR/STTR grantees have been selected to receive administrative
    supplements to provide summer research experiences for students and/or
    science educators.
        Question. My staff has been told by NIH officials that you are
    setting up a Pilot program for small businesses with your discretionary
    ARRA funds. Can you please report to the Senate Small Business
    Committee on the nature and progress of this Pilot program?
        Answer. You are correct, NIH recently announced the ARRA-funded
    BRDG-SPAN Pilot Program to focus on the gap between research and
    development and transitioning to the market.
        Only U.S.-owned for-profit enterprise/commercial organizations may
    apply, and although not explicitly limited to small businesses, most of
    the applications are expected to be submitted by small businesses.
    Applications received under this funding opportunity may be given
    funding priority if the applicant is associated with an enterprise/
    commercial organization that is of small size and/or of limited
    resources.
        In addition, we have another ARRA-funded small business program
    called the Catalyst Awards, and only U.S. small business concerns are
    eligible to submit SBIR applications.
        Question. I have looked at a number of legislative vehicles,
    including the fiscal year 2010 Labor HHS Appropriations bill, to make
    up for the loss of money to small businesses that was created by the
    small business exemption in ARRA. Can you give me your thoughts on how
    this money can be made up, whether it be legislatively or through
    proactive actions by the NIH?
        Answer. NIH's current commitments to small business research
    instill confidence that this research community will receive a fair
    portion of NIH's extramural funding. This is already in evidence, since
    a large number of applications were received from small businesses in
    response to our initial ARRA-supported FOAs, and applications are still
    being received from small businesses in response to ARRA FOAs that
    remain open.
                                     ______

                  Questions Submitted by Senator Arlen Specter
                    maternal fetal medicine research network
        Question. I am aware of the critical research conducted by the
    National Institute of Child Health and Human Development (NICHD)
    Maternal Fetal Medicine Research Network in the area of preterm birth
    and maternal complications. What are your plans for this Network in the
    fiscal year 2010 budget?
        Answer. The Maternal Fetal Medicine Units Network (MFMU) is one of
    the landmark research networks within NICHD. Conducting research that
    may affect pregnant women and their offspring can present some critical
    health and ethical issues. Yet improvements in clinical practice and
    care are dependent on evidence-based research, and the Network was
    created in response to this need. This research mechanism permits
    large-scale clinical studies that provide the necessary information to
    allow healthcare professionals to translate the findings into everyday
    clinical practice.Specifically, the MFMU Network conducts clinical
    trials and observational studies in obstetrics to improve maternal and
    neonatal outcomes. It is essential for each Network participant to
    conduct this work in the same manner (i.e. following the same protocol)
    in order to have comparable results that can be applied across the
    Nation and for different population groups. In addition, preventive
    measures and interventions can be tested to find out if they work, or
    just as important, if they do not.
        NICHD has spent approximately $170 million since the MFMU Network's
    inception in 1986. It is re-competed every 5 years to ensure that only
    the best scientists are funded to do this work. The existing network
    will expire in fiscal year 2011. The networks scientific success
    supports considering a new competition in fiscal year 2011. As is
    typical, decisions regarding extending the Network will be made during
    development of the 2011 budget. Current projections for fiscal year
    2010 are $12.6 million in NICHD funding. Along with a projected
    $700,000 contribution from NINDS in fiscal year 2010, the total support
    level comes to $13.3 million.
                              salivary diagnostics
        Question. Dental schools, and I have one in my State, are doing
    some rather exciting research in the area of saliva as a diagnostic
    tool. Where does this research stand at this point?
        Answer. Saliva is a complex mixture of water, antibodies, and other
    specialized protective proteins, important for maintaining oral health,
    function, and comfort. It has long been recognized that saliva acts as
    a mirror of the body's health, in that it contains the full repertoire
    of proteins, hormones, antibodies, and other substances that are
    frequently measured in standard blood tests to monitor health and
    disease. Saliva is easy to collect, even repeatedly if needed, and
    poses none of the risks, fears, or invasiveness of blood tests.
        Saliva has already been used reliably to detect a number of
    diseases, including HIV, as well as viral hepatitis A, B, and C. It
    also can be used to monitor a variety of drug levels, including those
    of marijuana, cocaine, and alcohol. The National Institute of Dental
    and Craniofacial Research (NIDCR) is supporting efforts to identify and
    validate biomarkers, and to also support technology to overcome
    barriers to the widespread use of salivary diagnostics. For example
    researchers are focused on developing microchip assays for point-of-
    care delivery, and are making impressive progress at achieving high-
    sensitivity, high-specificity, miniaturization, automation,
    portability, low cost, speed, and the ability to assay a large number
    of samples and biomarkers concurrently.
        Last year, scientists funded by NIDCR completed the first full
    catalogue of proteins present in saliva. This protein dictionary will
    serve as an essential reference point as scientists continue to
    validate saliva as a diagnostic fluid. This resource also complements
    our growing ability to leverage DNA and RNA as biomarkers. For example,
    in October 2008, NIDCR-supported scientists reported that they could
    use a panel of 5 RNA biomarkers to accurately detect oral squamous cell
    carcinoma, a form of oral cancer, more than 90 percent of the time.
        Question. Is progress being made?
        Answer. Yes, progress is being made. The field of salivary
    diagnostics combines the power of mathematics, biology, genomics,
    proteomics, engineering, computer science, and other areas, with the
    goal of using saliva as a diagnostic fluid for a variety of conditions,
    from AIDS to cancer to diabetes. Several NIDCR grantees are now working
    to develop and assemble tiny ``labs on a chip'' that can precisely
    measure levels of the various antibodies, antigens, and nucleic acids
    present in saliva, all of which may indicate a developing disease or
    condition. In contrast to existing blood tests which require painful
    needle sticks, salivary tests could be performed on the spot and
    rapidly scan oral fluids for the presence or absence of multiple
    proteins linked to various systemic diseases and conditions. NIDCR is
    currently supporting the development of devices that will detect
    infectious diseases, cancer, renal diseases, steroid hormones, and
    inflammatory markers for cardiovascular and pulmonary diseases. The
    technologies being developed also will be effective for tracking new,
    as-yet unidentified biomarkers.
        As an illustration of progress in this area, NIDCR scientists
    recently reported clinical success in detecting C-reactive protein in
    human saliva with an ultrasensitive microchip assay system. C-reactive
    protein, a serum protein indicative of inflammation, is elevated in
    people with periodontal disease and may be predictive of developing
    heart disease.
        Question. Will we be able to go to our dentist and undergo this
    noninvasive diagnostic test to detect early markers of diseases, such
    as Alzheimer's disease, pancreatic, and breast cancer?
        Answer. This is part of our vision for the future; saliva is easy
    to collect and poses none of the risks, fears, or invasiveness of blood
    tests. The miniaturization of detection devices may allow placement of
    the sentinel device directly in the mouth, yielding real-time
    surveillance of hundreds of biomarkers that could alert individuals to
    consult with their health professionals at the earliest moment of
    disease, or to monitor the progression and recurrence of diseases in
    patients undergoing treatment. This will enable oral healthcare
    professionals to assume a more prominent role in primary care and
    disease prevention that will assume increasing importance as the
    American population ages. NIDCR will continue to support ongoing
    studies, as well as new studies including those made possible by
    American Recovery and Reinvestment Act funding, that will examine the
    feasibility of developing salivary diagnostic testing for the early
    markers of a number of diseases, including Alzheimer's disease and
    several cancers. The recent success of NIDCR-supported researchers in
    identifying salivary markers for primary Sjogren's syndrome, a chronic
    autoimmune condition of the salivary and tear glands that affects about
    2 million Americans, mainly women, is another example of progress in
    this area.
        Salivary diagnostics could have benefits far beyond medicine and
    dentistry as well. For example, law enforcement agencies could employ
    saliva tests both forensically and in the field to determine rapidly
    whether a person is intoxicated or has recently used illegal drugs.
    These tests may also be beneficial in determining exposures to
    environmental, occupational, and biological substances, such as
    anthrax.
                    nih budget with presidential initiatives
        Question. The budget presented provides an increase of $174 million
    for all research except cancer. Will this essentially flat budget
    funding be sufficient to meet the important research work being
    conducted by the National Institutes of Health (NIH)?
        Answer. We believe that the fiscal year 2010 NIH funding priorities
    are sound and will ensure the rapid translation of science from the
    laboratory to the bedside. The budget supports more than 9,800
    competing Research Project Grants in addition to exponentially funding
    cancer as an initiative.
        NIH's research categories are not mutually exclusive and individual
    research projects can be included in multiple categories as in cancer
    research; we have seen progress in one disease often comes from
    unrelated areas of investigation, and through the mutual synergy of
    such research that transformational findings occur. NIH will continue
    to fund high-quality research in all areas of its portfolio and will
    continue to effectively use every resource we receive in support of
    biomedical research.
                                   stem cells
        Question. What do you think is necessary in terms of time and
    funding to make research breakthroughs in stem cell research?
        Answer. The NIH has been clear that the best way to make
    breakthroughs in stem cell research is to pursue all avenues of stem
    cell research simultaneously as: (1) it is impossible to predict which
    type of stem cell research (e.g., adult or human embryonic) will
    ultimately yield the most successful approach in any given stem cell
    application; and (2) work in both adult and embryonic stem cells
    continues to inform and facilitate progress in stem cell research.
        It is difficult to predict a timeline for scientific breakthroughs
    or determine a budget that will achieve these breakthroughs for stem
    cell research or any other type of research. Since 2001, NIH has been
    the lead Federal agency supporting and conducting human embryonic stem
    cell (hESC) research, spending over $262 million on hESC research
    during this period. This research has significantly enhanced our
    understanding of the basic biology of these unique cells. For example,
    the genes required for maintaining pluripotency were determined by
    studying hESCs which led in 2007 to the breakthrough discovery of
    human-induced pluripotent stem cells. These cells are now being studied
    along with adult and hESCs to elucidate the unique characteristics and
    potential uses of each cell type.
        As you are aware, President Barack Obama signed Executive Order
    13505 on March 9, 2009, which requires NIH to establish new guidelines
    for Federal funding of human embryonic stem cell (hESC) research. NIH
    will issue the final guidelines by July 7, 2009. These new guidelines
    should increase ethical oversight and the number of responsibly derived
    hESC lines eligible for Federal funding. We anticipate that NIH will be
    able to provide support for research using many new hESC lines that
    were not previously eligible for Federal funding. It is our expectation
    that the expansion of the number of human embryonic stem cell lines
    available to scientists funded by NIH will hasten stem cell
    breakthroughs.
        As you know, there has never been a cap on how much NIH could
    potentially spend on stem cell research, adult or embryonic. Instead,
    the amount spent depends on the number of highly meritorious stem cell
    grants that are submitted by the scientific community. The scientific
    community has told us about additional research that will be enabled by
    the increase in the number of human embryonic stem cell lines eligible
    for Federal funding that will result from the new policy. Once the new
    Guidelines are in place, NIH will assess the research needs and
    opportunities in stem cell biology and will develop initiatives that
    meet those needs to capitalize on these opportunities.
                                  lower lp(a)
        Question. Several years ago, I asked Dr. L'Enfant about your
    research for a medication to lower Lp(a). Is there anything new that
    you can tell me about the status of research toward a medication that
    lowers Lp(a)?
        Answer. Of all the drugs we currently use to treat abnormal
    lipoproteins, the one that most consistently lowers Lp(a) levels is a
    drug that has been around quite a while--niacin. Although the National
    Heart, Lung and Blood Institute (NHLBI) does not ordinarily sponsor
    drug development, as that is the province of the pharmaceutical
    companies, we are currently supporting a very important randomized
    clinical trial called AIM-HIGH. The trial is testing whether an
    extended release form of niacin (Niaspanr) will improve outcomes in
    3,300 patients who have cardiovascular disease and ``atherogenic
    dyslipidemia,'' a fairly common constellation of lipoprotein
    abnormalities associated with high cardiovascular risk that often
    includes high Lp(a) levels. We have funded an ancillary study to the
    AIM-HIGH trial specifically to learn more about how niacin affects
    lipoproteins, including Lp(a), and to determine the extent to which the
    effects may explain any observed improvement in cardiovascular
    outcomes. The information this study will provide about the role of
    Lp(a)in cardiovascular disease may help inform subsequent drug
    development efforts.
                                 curing cancer
        Question. The cancer community has indicated that $335 billion over
    the next 15 years is necessary to make real progress toward cancer
    cures. What do you think is necessary in terms of time, funding, and
    research breakthroughs to make a real difference in curing cancer?
        Answer. The National Cancer Institute (NCI) is currently working
    with the other Institutes and Centers at NIH to develop an NIH cancer
    research strategic plan for the proposed plan by President Obama to
    double cancer research funding over the next 8 years. The strategic
    plan recognizes that most advances in the field will be made because of
    the knowledge that cancer is a disease of genomic alterations and of
    tumor cell evolution.
        The NCI is developing a personalized cancer care platform--based
    upon the knowledge that cancer is a disease of altered genes--that will
    encompass and enable a drug development platform, from discovery of
    genetic changes to translation to man. Advanced genome sequencing
    technology will soon make it possible to completely sequence both
    normal and disease tissue of individual patients. NCI is developing a
    comprehensive approach to translate raw genetic information into an
    intimate understanding of the function of the genetic pathways which
    can then be used to clearly define targets for manipulating those
    pathways to inform the development of new targeted interventions. NCI
    is taking steps to create the first of a small national network of
    tumor characterization centers that will match a genetically
    characterized patient's tumor to appropriate and optimal therapeutic
    solutions. This 21st century vision for personalized medicine will
    connect individuals, organizations, institutions, and the concomitant
    information in a cycle of discovery, development, and clinical care.
        As the leader of the National Cancer Program, NCI is building on
    its history of research success and wisely spending every dollar it
    receives in a continual effort to foster the best research and to
    connect the public, private, and academic sectors for effective
    translation of these discoveries. With the significant funding
    increases proposed by the President, NCI could realize the promise of
    personalized cancer care more rapidly by significantly shortening the
    path between making an innovative discovery in the laboratory to having
    an effective impact on a patient in the clinic.
        In this new era of post-human-genome science, it is clear that
    multiple new agents will be necessary to target multiple cancer
    pathways in each unique patient. Small molecules will penetrate cancer
    cells. New agents will energize the body's immune system to fight
    tumors. Still other agents will target the seemingly normal tissue of
    the tumor microenvironment or the tumor initiator cells with ``stem-
    like'' characteristics that may lead to cancer's deadly spread.
    Consequently, we will need to continue to expand discovery of the
    underlying genetic signatures of cancer and to develop individual
    recipes of therapy, often using multiple drugs from multiple
    manufacturers.
        It is in the area of developing orphan drugs or combination
    therapies where industry--concerned about marketability, intellectual
    property, competition, and liability issues--often fears to tread. NCI
    must fill that void:
      --Through increased funding of the Developmental Therapeutics Program
            and other allied programs, NCI could greatly expand a cohesive
            effort to produce small quantities of new agents and begin
            first-in-human testing, which would, in turn, lead to
            commercialization at a more rapid pace.
      --Through a well-financed, coordinated plan, NCI could importantly
            restructure how it conducts clinical trials, creating an
            electronically connected system capable of bringing early phase
            clinical research to millions more patients, in their home
            communities.
      --Through strategically placed characterization centers, NCI could
            conduct the intensely technological and specialized testing
            necessary in an era of targeted agents. This effort could
            create the standards of tumor analysis required in this new
            age, and could more effectively address the demands of rapidly
            changing technology. Examples of needed programs include early
            phase pharmacodynamic studies, a U.S. oncology tissue bank and
            certified centralized tumor characterization laboratories.
      --Additional development of advanced technologies will allow us
            further develop nanoparticles designed to penetrate tumors and
            conduct greater research into the telltale proteins in the body
            that could be used to enhance early diagnosis. Enhancing
            technology development in clinical proteomics, systems biology,
            and increasing our biomedical computing capabilities would
            accelerate progress against cancer, but could also be applied
            to understanding other diseases.
      --Through greater development of imaging, science could refine and
            improve the capacity to look inside cells, revealing biological
            processes in real time. This effort could develop the next
            generation of tools for early diagnosis, at a time when there
            are only a few million cancer cells in a patient's body.
                                     ______

                  Questions Submitted by Senator Thad Cochran
                                  sarcoidosis
        Question. Sarcoidosis is a systemic inflammatory disease and one of
    the most common causes of fibrotic lung disease in the United States.
    Sarcoidosis can cause chronic debilitating or life-threatening heart,
    neurological, and internal organ disease and has no safe, effective
    treatments. In North America, African Americans are about five times
    more likely to have sarcoidosis than whites, representing a significant
    national health disparity. Despite the substantial burden of this
    illness on many (tens of) thousands of Americans of all races, and
    significant recent progress in our understanding of the illness, the
    National Institutes of Health (NIH) has supported disproportionately
    little research for this disease relative to its burden of disease, a
    disparity that has been increasing over the past decade. What do you
    believe are the reasons for this disparity and how can it be corrected?
        Answer. The National Heart, Lung and Blood Institute (NHLBI) has
    had a long-standing commitment to funding research on the causes and
    treatment of sarcoidosis and on genetic predisposition to developing
    it. In recent years the Institute developed several new initiatives
    specifically addressing sarcoidosis, including a solicitation on
    granulomatous inflammation in sarcoidosis that resulted in funding of
    11 new research projects. The Institute currently supports exciting
    programs in genomics of sarcoidosis and a new clinical trial on
    atorvastatin as a disease-modifying agent in pulmonary sarcoidosis. One
    reason for the funding disparity may be the small numbers of
    investigators in the country who are interested in conducting research
    in this complex and multi-organ disease. In addition, applications
    submitted have not competed well. Some steps we are taking to address
    this disparity include increasing visibility of sarcoidosis through
    activities such as radio spots on the disease; developing new research
    initiatives to address specific aspects of the disease; and working
    with the Trans NIH Sarcoidosis Working Group, which coordinates
    sarcoidosis research activities across the NIH. One of its recent
    activities has been promotion of a workshop on the genetics of
    sarcoidosis that was held last summer. Workshop recommendations, which
    have been posted on the NHLBI Web site, include initiation of a
    community-based study of sarcoidosis that would develop a registry of
    clinical information about the disease and might also include
    collection of patient samples for genetic studies. Other
    recommendations were to promote collaboration on sarcoidosis with
    NHLBI-funded investigators and the scientific community in Europe and
    other parts of the world, and to launch a genome-wide association study
    (GWAS) based on available samples from ACCESS and other existing
    cohorts. NHLBI staff are following up on these recommendations. Via the
    NIH solicitation for Challenge grants under the American Recovery and
    Reinvestment Act (ARRA), the NHLBI requested GWAS on rare lung
    diseases, including sarcoidosis.
        Question. What are the plans of the NHLBI for closing this gap and
    improving the clinical care and treatment for patients with
    sarcoidosis?
        Answer. Our plan is to support ongoing and new meritorious research
    through both ARRA and traditional investigator-initiated applications;
    re-issue an NIH-wide sarcoidosis program announcement, which seeks to
    stimulate research on the multi-organ manifestations of the disease;
    continue support of the NHLBI atorvastatin clinical trial; and consider
    future initiatives based on the NHLBI workshop on genetics of
    sarcoidosis that was held last summer. A new initiative under
    consideration addresses cardiac dysfunction associated with
    sarcoidosis. We are optimistic that these efforts will lead to advances
    in understanding the origin and pathogenesis of this disease and will
    improve our ability to diagnose and treat affected individuals.
                                     ______

                Questions Submitted by Senator Richard C. Shelby
                        clinical and transational awards
        Question. The Clinical and Translational Science Awards (CTSA) is
    designed to transform how clinical and translational research is
    conducted, ultimately enabling researchers to provide new treatments
    more efficiently to patients. Tremendous effort has brought
    institutions together to rally around this program, yet current funding
    levels make it difficult for the programs to succeed. Key to the
    success of the CTSA is the development of cost sharing for use of
    infrastructure services. An example of this mechanism is the General
    Clinical Research Centers (GCRC), which allowed institutes to reduce
    their research budgets by having investigators use the GCRC when
    clinical care such as inpatient stays, lab tests, and nursing staff was
    made available at no additional cost. Today, individual investigators
    must provide funds for clinical care cost sharing from grants funded
    from other National Institutes of Health (NIH) Institutes. As research
    becomes more expensive and private capital dries up, it becomes even
    more critical to ensure support for translational research, that is,
    research that moves a potential therapy from development to the market.
    Will the NIH provide the financial resources necessary to maximize the
    potential of this critical program?
        Answer. The CTSA program is providing substantially more funding
    for clinical research than was available under the GCRC program. The
    CTSA allows the institution to continue activities that were conducted
    in the GCRC and add new activities. With a minimum total funding level
    of $4 million per year, all CTSAs will be able to offer clinical
    investigators a substantial diversity of resources. The prioritization
    of resources offered within an institution is determined locally, as
    are any needs for cost sharing to ensure adequate support for a wide
    range of activities.
        National Center for Research Resources (NCRR) expects to fulfill
    the charge to transform clinical and translational research within the
    current overall budget for the program. At $500 million per year when
    fully implemented, the CTSA program represents a significant increase
    in infrastructure support over the $340 million allocated to pre-
    existing NIH clinical research resources (i.e., NCRR K12, GCRC M01, NIH
    K30, and Roadmap T32 and K12 programs). To reach the critical mass
    necessary to transform clinical and translational research, NCRR
    projects that 60 CTSAs are needed throughout the United States.
    Diversity in the size, scope, and geographic location of participating
    institutions will strengthen the CTSA consortium and enhance its
    national and regional collaborations

                             CONCLUSION OF HEARING

        Senator Harkin. So again, I thank you all very much, and
    with that the subcommittee will stand recessed.
        Dr. Kington. Thank you.
        [Whereupon, at 11:49 a.m., Thursday, May 21, the
    subcommittee was recessed, to reconvene subject to the call of
    the Chair.]

      DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES, AND EDUCATION, AND
              RELATED AGENCIES APPROPRIATIONS FOR FISCAL YEAR 2010

                                  ----------

                            WEDNESDAY, JUNE 3, 2009

                                           U.S. Senate,
               Subcommittee of the Committee on Appropriations,
                                                        Washington, DC.
        The subcommittee met at 9:30 a.m., in room SD-124, Dirksen
    Senate Office Building, Hon. Tom Harkin (chairman) presiding.
        Present: Senators Kohl, Murray, Landrieu, Reed, Pryor,
    Specter, and Cochran.

                            DEPARTMENT OF EDUCATION

                            Office of the Secretary

    STATEMENT OF HON. ARNE DUNCAN, SECRETARY
    ACCOMPANIED BY THOMAS SKELLY, DIRECTOR, BUDGET SERVICE

                    OPENING STATEMENT OF SENATOR TOM HARKIN

        Senator Harkin. Good Morning. The Labor, Health and Human
    Services Education Appropriations Subcommittee will come to
    order. I want to start by welcoming Secretary Duncan. I was
    honored to chair the confirmation hearing on the other
    committee on which I sit. But this is his first appearance
    before this subcommittee, so he's here to talk about money, the
    taxpayers' money.

                     AMERICAN RECOVERY AND REINVESTMENT ACT

        Every year when Congress considers the President's budget
    it hears people say it is a critical moment in the Nation's
    history. In hindsight, some of those moments were probably more
    important than others, but I would submit when it comes to
    education, this is truly one of those historic moments. The
    Recovery Act will add almost $100 billion to the Nation's
    education system. The largest one-time investment in education
    in our history, and that's on top of the more than $60 billion
    in the regular 2009 bill. There has never been this much
    funding in the Nation's schools before in our history. So we in
    Congress, especially on this subcommittee, and the Education
    Department have a special responsibility to make sure that the
    money is used wisely.
        Funding of this scale brings in opportunities both to help
    to pull our economy out of the recession and to encourage new
    innovations in the way we educate our students. But if we are
    not careful, the money can also be squandered. Therefore, we
    will spend part of today's hearing talking about the
    implementation of the Recovery Act so far, what the Department
    plans to do with the rest of the money for the months ahead.

                            POSTSECONDARY EDUCATION

        We will so consider the President's request for the fiscal
    year 2010 budget. I think there is much to admire in his
    proposal, and am especially pleased by his plan to end
    entitlements for financial institutions that have processed
    Federal student loans and switch to direct lending, instead.
    This plan will save billions of dollars a year that can be re-
    invested, to help middle- and low-income students get a college
    education.
        The President's budget also puts real money behind efforts
    to improve our Nation's high schools. And the other end of the
    education spectrum, the budget request makes a strong
    investment in early learning.

                               SCHOOL FACILITIES

        One area that is not addressed in the President's budget is
    school repair: renovations, repair, and construction. A last-
    minute decision to remove funding designated to that purpose in
    the Recovery Act was, in my opinion, a grave mistake. This
    money would have created jobs, met a pressing educational need
    and avoided long out-year funding commitments.
        But even though the funding was pulled from the Recovery
    Act, the need for better school facilities grows with each
    passing day. I recently introduced the School Building Act of
    2009, and I intend to include money for this purpose in the
    regular fiscal year 2010 appropriations bill.
        So, Mr. Secretary, I look forward to hearing your testimony
    about the President's budget, also the Recovery Act and other
    items that will come up here.
        First, I would yield to Senator Cochran. Thank you.

                       STATEMENT OF SENATOR THAD COCHRAN

        Senator Cochran. Mr. Chairman, thank you. I am pleased to
    join you in welcoming this distinguished Secretary to our
    subcommittee to review the budget for the next fiscal year. We
    appreciate your cooperation and look forward to working with
    you through the year. As we proceed with our deliberations on
    the budget request, the budget the President has submitted, I
    would ask, Mr. Chairman, that the balance of my remarks be
    printed in the record.
        Senator Harkin. Thank you, Senator Cochran. Senator Murray.

                       STATEMENT OF SENATOR PATTY MURRAY

        Senator Murray. Thank you very much. Mr. Chairman, Senator
    Cochran, thank you so much for having this hearing. Secretary
    Duncan, welcome. I am looking forward to hearing you talk today
    about the budget request and a wide range of educational
    challenges that you are addressing, both opportunities and
    priorities. These are issues that I have been focused on a very
    long time, both as an educator and as a member of this
    subcommittee. So I was very pleased to see that you and the
    President are preparing to tackle or more appropriately, put a
    full-court press on a lot of the large issues facing us in
    education today.

                            POSTSECONDARY EDUCATION

        The budget takes some exciting steps forward. I was very
    happy to see the College Access and Completion Fund, that will
    help our students enter and succeed in college. I think that's
    a promising idea. I look forward to hearing more about that.
    That's been a long-time issue of mine, especially for
    disadvantaged students, and Washington State has some
    innovative work in this area, so I'm looking forward to hearing
    some comments on that.
        I am also very encouraged by the President's goal that
    every student will complete at least 1 year of postsecondary
    education. I share that goal, and as a long-time advocate for
    job training and education programs, it's great to have a
    strong partner in the White House on that.
        I discussed with you earlier one of my innovations to 21st
    century careers, and looking forward to your work in that area
    as well.

                           PROPOSED BUDGET INCREASES

        I am pleased that your budget proposal has some significant
    increases in Pell grants, teacher quality, State grants, school
    leadership for principals, and literacy efforts. Those are all
    very important in our work today.
        This is a very ambitious education agenda and it comes at a
    very difficult time. At home, every weekend I go home and I see
    more headlines about teachers being laid off and the challenges
    in our educational system. I can tell you that teachers in my
    home State and across the country are not only worried about
    their own job security, but the impact on their students, as a
    lot of our States are facing some very tough times.

                               PREPARED STATEMENT

        So our work on the Recovery package to support our schools
    is very important, and I look forward to what you have to say
    about that as well today. And Mr. Chairman, just as a note of
    personal privilege, I want to just mention, I've got some
    students from one of our high schools in Washington State,
    Meadowdale. If you guys could just stand up? They are here all
    the way across the county and I remind all of us, this is what
    we are talking about today. So thank you for being here.
        Senator Harkin. Welcome. Where do you say they are from?
        Senator Murray. Meadowdale High School, Lynnwood,
    Washington.
        And, I would like to quickly mention their names for the
    record: here with us today is: Joshua Gregory; Aaron Feldhaus;
    Andy Nguyen; Morgan Buckingham; Samuel Triece; Evan Primm;
    Robert Baldridge; Matthew Genetiano; Dalia Mendoza; Andrew
    Prichard; Anwar Bible; Noah Beardsley; and Jacob Grund.
        [The statement follows:]
                   Prepared Statement of Senator Patty Murray
        Thank you Chairman Harkin and Senator Cochran for holding today's
    hearing to discuss the need to invest in education and prepare our
    young people to succeed in school and beyond.
        I also want to thank Secretary Duncan for joining us today to
    present the Department's budget request and discuss our wide-range of
    education challenges, opportunities, and priorities.
        I have been focused on these issues for years--both as an educator
    and as a member of this subcommittee.
        And I'm pleased to see that you and the President are preparing to
    tackle--or maybe more appropriately--put a full-court press on so many
    of the large, tough issues facing our education system. And this budget
    certainly takes steps forward on some very exciting education programs.
        The College Access and Completion Fund to help students enter and
    succeed in college is a promising idea. College access and completion,
    especially for disadvantaged students, has long been a goal of mine,
    and my home State of Washington has done some particularly innovative
    work in this area.
        Specifically, they have focused on partnerships with State and
    nonprofit programs to follow up with students throughout college to
    ensure their success.
        I look forward to working with you on the College Access and
    Completion Fund and keeping in touch as this process moves forward.
        I am also encouraged by the President's clear goal to that every
    student will complete at least 1 year of post-secondary education. I
    share President Obama's goals, and as a long-time advocate for job
    training and education programs for our workers, I am glad to have a
    strong partner in the White House.
        To address this goal, I will be re-introducing my bill, the
    Promoting Innovations to 21st Century Careers Act, that works to bridge
    the skills gap between what students need to know to be successful and
    what skills employers, colleges, and communities are looking for.
        I am pleased that your budget proposal has significant increases in
    Pell grants; Teacher Quality State Grants; The School Leadership
    Program for principals; and literacy efforts.
        These are all going to help ensure that our students have access to
    high-quality education--from early childhood all the way through
    college.
        You and President Obama have taken on an ambitious education
    agenda, and we know that it comes at a difficult time. Every day there
    is another front page story somewhere in my state about teachers being
    laid off or education programs being cut or cancelled.
        Teachers are worried about job security and parents are worried
    about quality or how to pay to send their kids to college.
        I am proud that our work together to pass a strong Recovery package
    is beginning to help States like Washington keep more teachers in their
    jobs and continue our national commitment to ensuring a quality
    education for all students.
        But as you know well, our long-term economic recovery is going to
    depend on sustained investments and new and innovative programs that
    will give our kids the skills to succeed in higher education and
    careers in the 21st century economy.
        I look forward to asking you questions on efforts to build those
    skills and on the investments proposed in your budget.
        Thank you.

        Senator Harkin. Welcome to Washington. Thank you, Senator
    Murray. Senator Reed.

                         STATEMENT OF SENATOR JACK REED

        Senator Reed. Mr. Chairman, I simply want to welcome the
    Secretary, and also underscore what Senator Murray said about
    the College Access and Completion Fund, much of which is built
    on the work that we advised them on last year, and I look
    forward to the Secretary's comments on how he is going to use
    the, I believe, gap provisions, and bolster this particular
    fund. Thank you.
        Senator Harkin. Thank you, very much, Senator Reed. Senator
    Landrieu.

                     STATEMENT OF SENATOR MARY L. LANDRIEU

        Senator Landrieu. Thank you, Mr. Secretary, just briefly, I
    want to thank you for your early visit right after your
    confirmation to New Orleans, to see their continued effort to
    rebuild their school system, not just in the city, but in the
    region. And most excitingly, Mr. Chairman, to build a brand new
    school system that's based on large measure on some of the work
    that has been done in this subcommittee and in our full
    Appropriations Committee, but now being led by Secretary Duncan
    and President Obama.
        And I just want to comment that some of the same principles
    about our rebuilding a new, revitalized public school system,
    we can take from that, and give options and opportunities for
    the rest of the country, particularly, Mr. Chairman, the focus
    on expanding our commitment to quality charter schools, which
    are independent public schools, to some degree, that are
    showing extraordinary promise across the country. And I want to
    thank the Secretary for his leadership and just say that this
    budget is not only a commitment to bold reform, but I am also
    excited about your commitment to funding and the President's
    commitment to that goal of reform. Because that didn't happen
    in the last administration, and I'm very excited that the
    commitment to funding and the commitment to excellence have
    been put together, and under your extraordinary leadership, I
    think we can get it accomplished.
        Thank you.
        Senator Harkin. Thank you, Senator Landrieu. Now, Secretary
    Duncan, welcome. Your statement is being made part of the
    record in its entirety, and please proceed as you so desire.

                     SUMMARY STATEMENT OF HON. ARNE DUNCAN

        Secretary Duncan. Thank you, Mr. Chairman, for your
    leadership. I have gotten a chance to spend time with many of
    the subcommittee members and I haven't seen more passion and
    commitment to education anywhere. So I am very excited at the
    opportunity to work with you and try and do something
    dramatically better for the children of our country.

                  FISCAL YEAR 2010 EDUCATION BUDGET PRIORITIES

        Thank you so much for the opportunity to be here today to
    talk with you about President Obama's fiscal year 2010 budget
    request.
        Senator Harkin. Mr. Secretary, is your mike on or if it is,
    can you pull yourself a little bit closer?
        Secretary Duncan. 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 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 an
    assurance that the Federal Government will be there to help
    them. Together, all of these policies will help our country
    reach the President's ambitious goal, that by 2020 the United
    States will once again have the largest proportion of college
    graduates in the world.

                   IMPACT OF RECOVERY ACT FUNDS ON EDUCATION

        I am extremely grateful for the work you have already done
    to help our Nation's schools. I look forward to working with
    you in the future. As you know, in the American Recovery and
    Reinvestment Act (ARRA), you provided $100 billion to schools
    and to students. The law provides a great, great start in
    addressing the needs at every point along the cradle to career
    spectrum. Thanks to your support, we are able to stave off an
    education catastrophe and save a generation of children.
        As you know, the ARRA had two goals in education: to create
    and preserve jobs, and to promote school reforms. Even though
    the Department of Education hasn't yet distributed all of the
    money provided in the stimulus bill, we are seeing signs that
    we are meeting the goal of preserving the jobs of teachers and
    other educators.
        We are collecting data on the number of jobs preserved, and
    can point to several districts where the stimulus funding has
    made a significant difference.
        Because of ARRA, the Los Angeles Unified School District
    averted almost 3,800 layoffs. In New York City, that number is
    14,000 layoffs averted, 139 teachers kept their jobs in
    Seminole County, Florida, and in Boston, teacher union leaders
    say the stimulus money ensures that the city won't lay off any
    teachers. Alabama's State superintendent has said that the
    stimulus money will help avert all layoffs in his State as
    well.
        I am confident that in just about all our 14,000 districts
    around the country, the stimulus money will be used to preserve
    jobs that otherwise would have been lost, or to create jobs
    they'd never have been able to add if they didn't receive money
    from the ARRA.

                  EDUCATIONAL ASSURANCES FOR EDUCATION REFORM

        Before this stimulus, we were heading for an educational
    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.
        Through ARRA, States are promising to make commitments on
    policies that we consider to be essential for 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 work force 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, States
    will commit to fixing the lowest performing schools. Finally,
    they will build or enhance 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 help. This
    information must also be put in the hands of educators, so they
    can use it to improve instruction.

                         INCREASING INSTRUCTIONAL TIME

        Another key ingredient of 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 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 and the school year. In
    places like Cincinnati, we are already seeing such innovation
    taking place. Cincinnati is adding what they are calling a
    fifth quarter, where students must spend an extra month in
    school this summer.
        This is also a key component of our school turnaround
    strategy, because we know that kids who are struggling
    absolutely need more time in order to catch up.

                              RACE TO THE TOP FUND

        Through ARRA, we will be rewarding States, districts, and
    nonprofit leaders who are dedicating themselves to moving
    forward in each of these areas of reform. The $4.35 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 the rest of the country to follow.

                         WHAT WORKS AND INNOVATION FUND

        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 awarding grants in the late fall. 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.

                 FISCAL YEAR 2010 DISCRETIONARY FUNDING REQUEST

        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.

                              EDUCATION PRIORITIES

        I want to highlight our request in several important areas:
    early childhood education, improving the pay and professional
    development of teachers, turning around low-performing schools,
    and ensuring that college students have financial aid and
    student loans. They need not just to enter college, but to
    complete. Again, the goal is not just access, it's attainment.

                           IMPROVING TEACHER QUALITY

        In K-12 education, we are requesting two important
    investments in the key priorities identified under the
    stimulus: improving the quality of our teachers and turning
    around low-performing schools. In other countries, the top one-
    third of college graduates enter the teaching force.
    Unfortunately, too often here in the United States, our best
    college graduates choose other professions. We need to change
    the way we promote and compensate teachers, so that we can
    attract the best and brightest into the profession by rewarding
    excellence and providing supports that enable success.

                     TURNING AROUND LOW-PERFORMING SCHOOLS

        As for turning around low-performing schools, we all know
    that too many of our schools are actually 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 freshmen 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 have asked 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 them, with a
    strong focus on dropout prevention in these so-called dropout
    factories.

                    ECONOMIC IMPACT OF HIGH SCHOOL DROPOUTS

        And just to pause for a moment, our dropout rate for our
    country--for the Nation is approximately 30 percent. So it's a
    problem that plagues every community: urban, rural, and
    suburban. Recently the Alliance for Excellent Education came
    out with a study on the cost to the economy of the dropouts of
    the class of 2008; had they graduated and not dropped out, that
    would have added an additional $319 billion in income over
    their lifetimes. And if we don't do something about this
    dropout crisis, over the next decade the loss to our country
    will be $3 trillion. So the economic impact, beyond the lost
    human potential, is something we absolutely have to come to
    grips with.

                           SCHOOL IMPROVEMENT PROGRAM

        Our budget includes $1.5 billion for the Title I School
    Improvement Program. That's 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
    year 2009, we will have more than $5 billion to help turn
    around low-performing schools.
        I am talking about dramatic changes here. I will not 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 improving student learning.
        I want superintendents to be aggressive and take the
    difficult step of shutting down a failing school and replacing
    it with one that will work.

                             TEACHER INCENTIVE FUND

        To improve both the quality of teachers and the critically
    important 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, I want the grants awarded under this
    program to be a cooperative effort between districts and
    teachers. The President has often said that he believes changes
    to the teaching profession should be made by working with
    teachers and 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 designed the
    framework that became our foundation.
        Together we created a program which emphasized improving
    professional practices of teachers, identifying what it takes
    to make teachers better, and rewarding those who improve.
        One important change that we are requesting to the Teacher
    Incentive Fund would allow districts to reward all of the
    employees of a school for helping that school to improve
    student achievement. Students excel and thrive when all adults
    in the school work together. The janitors, the custodians, the
    cafeteria workers, the security guards also need to be rewarded
    when students in their school succeed.
        I have seen throughout my life, that when every adult in
    the school building collaborates to create a culture of high
    expectations, magic happens for children.

                                READING PROGRAMS

        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 $70.4 million for that purpose, almost
    double the amount in the fiscal year 2009 budget.
        With the remaining $300 million, we will create a
    competitive grant program to support districts to create
    comprehensive and coherent programs that address the needs of
    our young readers. These programs would ensure that students
    learn all of the skills they need to become good readers,
    teaching them everything from awareness to reading
    comprehension.
        We intend to build upon the successes and the lessons of
    the Reading First Program, while simultaneously fixing the
    problems.

                RECOVERY FUNDS FOR TITLE I AND SPECIAL EDUCATION

        I would like to say a word or two about the largest
    programs that have been entrusted to us: the title I program
    and the Special Education State Grants program under the
    Individuals With Disabilities Education Act, that Senator
    Harkin, you worked so hard on. Both programs received dramatic
    funding through ARRA.
        Title I received $10 billion in funding for grants to
    districts, in addition to the $3 billion for school improvement
    program, while Special Education State Grants received $11.3
    billion. That's almost as must as it 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 that money runs 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 in the Recovery Act and the period of availability.
        We hope to resume our commitment to funding the increases
    for the 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 in crisis.
        More of the same in our dropout factories will not help
    children succeed and beat the odds. That would only ensure that
    we, as educators, actually perpetuate poverty and social
    failure. We have too many examples of what does work and what
    is possible around the country to continue to allow devastating
    failure to exist.

                           EARLY CHILDHOOD EDUCATION

        In fiscal year 2010, we will also be making important
    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 the 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.

                    ARRA FUNDING FOR POSTSECONDARY EDUCATION

        All of those changes will help push school reform in K-12
    schools. We also have significant, important policy changes for
    higher education. The Recovery Act made an important down
    payment on our plans to expand student aid. And in addition to
    more aid, we want to make sure that more students are not just
    attending college, but also graduating.

                  BUDGET PROPOSAL TO MAKE PELL FUNDS MANDATORY

        The stimulus bill provided $17.1 billion so we could raise
    the maximum Pell award from $4,850 to $5,350. In the fiscal
    year 2010 budget, we propose important and permanent changes to
    ensure students will have access to Federal grant aid and
    loans. The first thing we propose is to move the Pell Grant
    program from a discretionary to a mandatory appropriated
    entitlement. Second, we propose to link the increase in the
    maximum grant to the consumer price index (CPI), plus 1
    percent, every year, which will allow the maximum grant to grow
    at a rate higher than inflation, so we can keep up with the
    rising cost of college.
        I am grateful for all of the work that the appropriators
    have done to fund annual increases for Pell grants,
    particularly in the last 4 years. But even with that
    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 assurances that they
    will have the assistance they need to make it through college.
    This is, of course, a major financial commitment.

                 PROPOSAL FOR ALL NEW LOANS TO BE DIRECT LOANS

        We are able to pay for this change, in part, by
    streamlining and improving the student loan program. We will
    move all 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 one additional dollar.

                PROPOSED BUDGET SAVINGS AND PROGRAM ELIMINATIONS

        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, to identify programs that
    are ineffective and too small to have a significant impact.
        Our student loan proposal saves more than $64 billion per
    year. In addition, we are proposing to eliminate 12 programs,
    creating an additional savings of $550 million. Even though we
    recommend cutting these programs, we remain committed to their
    goals. We are eliminating the $294 million State program under
    the Safe and Drug-Free Schools and Communities Program because
    several research studies have found that the program is
    ineffective. But we absolutely 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
    Program.
        Also, 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 is investing in our country's
    future economic security, and also making tough decisions to
    eliminate programs that are not working.

                               PREPARED STATEMENT

        I appreciate the opportunity to discuss our fiscal year
    2010 budget and look forward to your questions. Thank you so
    much.
        [The statement follows:]
                       Prepared Statement of Arne Duncan
        Mr. Chairman and members of the subcommittee: Thank you for this
    opportunity to testify on behalf of President Obama's fiscal year 2010
    budget for the Department of Education, and to talk with you about how
    together we can lay the foundation for a generation of reform that can
    restore American leadership in education.
        President Obama is asking for $46.7 billion in discretionary
    funding for the Department in fiscal year 2010, an increase of $1.3
    billion over the comparable 2009 level, that would build on the
    historic increases provided for education in the American Recovery and
    Reinvestment Act (Recovery Act).
        The combined resources of the Recovery Act and the 2010 request
    demonstrate the President's strong belief that improving education is
    the best way to ensure our long-term economic prosperity and security.
    Moreover, education is the civil rights issue of our generation, and
    the only truly effective weapon in our Nation's long war on poverty.
        And it's not just more money that has created this unprecedented
    opportunity to dramatically improve the quality of our education
    system, but also broad, bipartisan agreement on what needs to be done
    to achieve this goal.
        We need college-ready, career-ready, internationally benchmarked
    academic standards that reflect the fact that our kids today are not
    competing against children down the block or even across the country,
    but across the globe in countries like India and China. And to make
    sure all of our kids can meet those standards, especially those poor
    and minority children that currently suffer from the achievement gap,
    we need to invest more in quality early childhood education.
        We also must do everything we can to get a great teacher in front
    of every classroom in the Nation. Everyone knows the difference that a
    good teacher can make, but we have far too few good teachers in our
    most challenging, lowest-performing schools. We need to change the
    incentives to encourage our best teachers and principals to work in the
    toughest schools.
        And we need to be much more thoughtful about supporting reform and
    innovation that have been proven to increase student achievement. We
    need to identify and scale up best practices and promote effective
    strategies like expanding the number of charter schools and extending
    learning time to help turn around low-performing schools.
        All of these priorities--higher standards, early childhood
    education, better teaching, and promoting effective innovation--will
    help more students enter and graduate from college. There is no
    question that one key to success in the global economy is a college
    education, and President Obama has set a national goal of ensuring that
    America is number one in graduating young people from college by 2020.
    Today roughly 40 percent of 25-34 year-old Americans hold college
    degrees, and we want to raise that to 60 percent.
        The Recovery Act put significant resources--almost $100 billion--
    behind each of these strategies for ensuring that every child has the
    opportunity to obtain a quality education. Our 2010 request was
    developed in the context of Recovery Act funding, much of which will
    continue to be available to States and school districts in fiscal year
    2010, and reflects our effort to build on and make the most of that
    historic investment in education.
                           early childhood education
        We know from decades of research that investment in high-quality
    early childhood education and services leads to better outcomes in both
    school and the working world. President Obama is drawing on this
    research for his comprehensive Zero-to-Five initiative to expand access
    to quality childcare and education. The 2010 request would jump-start
    this initiative by helping to improve readiness for school,
    particularly in the area of early literacy and reading skills. For
    example, the request includes $500 million for Title I Early Childhood
    Grants, which would provide incentives for school districts to use a
    larger share of Title I Grants to local educational agencies (LEAs)
    funding--including the $10 billion provided by the Recovery Act--to
    establish or expand title I preschool programs. We also are asking for
    $300 million to launch the Early Learning Challenge Fund, which would
    lay the groundwork for future investments in early childhood education
    by helping to build State capacity to measure and improve the quality
    of early childhood programs.
        In addition, the 2010 request would strengthen early literacy
    through a $335 million increase that would expand the Striving Readers
    program to support comprehensive approaches to reading instruction for
    children in the elementary grades that are grounded in scientifically
    based reading research. A portion of the Striving Readers funds would
    continue to support interventions and whole-school efforts in secondary
    schools to help students who read significantly below grade level.
                     new incentives for effective teaching
        President Obama believes strongly that ``America's future depends
    on its teachers.'' We need more effective teachers, and we need them
    most in our lowest-performing schools. Our request supports both of
    these goals. For example, we are asking for a $420 million increase for
    the Teacher Incentive Fund to significantly expand programs developed
    with local stakeholders to reward effective teachers and principals and
    to expand incentives for teachers, principals, and other school staff
    to work in our most challenging schools. The request also includes
    $29.2 million for the School Leadership program, an increase of $10
    million, or 52 percent, to encourage effective principals to work in
    high-need schools and to train effective teachers to become principals
    or assistant principals in those schools.
                   promoting innovation in struggling schools
        Creating new incentives for teachers and principals is part of a
    broader effort in our 2010 budget to promote innovation and reform in
    low-performing schools. If you look on our website, at www.ed.gov, you
    will see that as part of our Recovery Act guidance we have posted a
    list of almost 13,000 schools that are identified for improvement
    during the current school year. That number is up by more than 1,000
    schools, or 9 percent, from the previous year. And more than one-third
    of these schools, or almost 5,000 schools, currently are in
    restructuring status--the final stage of improvement for chronically
    low-performing schools that demands fundamental changes in instruction
    and school governance to break the cycle of educational failure.
        Congress recognized the challenges that these schools create for
    States and school districts and provided $3 billion for Title I School
    Improvement Grants in the Recovery Act. The Department is working to
    maximize the impact of these funds on efforts to build State and local
    capacity to support school improvement, and the 2010 request would
    build on those efforts by seeking $1.5 billion for School Improvement
    Grants, a $1 billion increase over the regular 2009 level. The request
    would help intensify efforts to identify and adopt effective turn-
    around strategies. The request also would begin to help take on the
    dropout crisis by requiring States to ensure that 40 percent of School
    Improvement Grant allocations are spent in low-performing middle and
    high schools.
        In addition to school improvement funding, we are launching a major
    push to identify and scale-up best practices through our What Works and
    Innovation Fund, which received $650 million under the Recovery Act. We
    would add $100 million to this program in 2010, to support competitive
    grants to LEAs and partnerships between nonprofit organizations and
    LEAs that have made significant gains in improving student outcomes to
    expand or evaluate their work and serve as models of best practices. In
    many ways, this program is the linchpin of everything we are working on
    at the Department, because there is a huge need for effective, scalable
    strategies that can improve student achievement in high-poverty, high-
    need schools. Further, we request $72 million more for the Institute
    for Education Sciences, so we can identify what works based on rigorous
    research.
        Our 2010 request also would begin to make good on President Obama's
    promise to increase support for one innovation that we know can improve
    student achievement--charter schools. We are seeking a $52 million
    increase as part of a commitment to double funding for Charter Schools
    Grants over 4 years. Other activities in our 2010 budget to promote
    innovation include $50 million for a High School Graduation Initiative
    to fund innovative and effective strategies designed to increase the
    high school graduation rate, and $10 million for a Promise
    Neighborhoods initiative that would promote comprehensive programs that
    provide the support children need to achieve success from birth through
    college and beyond.
                        helping more kids go to college
        We announced most of our 2010 proposals for postsecondary education
    in February as part of the 2010 President's budget overview, so I will
    just summarize them briefly here. I do think we have an extraordinary
    story to tell about the Federal student aid programs. Under the
    President's request, the Department of Education would administer over
    $129 billion in new grants, loans, and work-study assistance in 2010--a
    32 percent increase over the amount available in 2008--to help more
    than 14 million students and their families pay for college. Our
    proposals to make Pell grants a mandatory, appropriated entitlement,
    raise the maximum Pell award from $5,350 to $5,550, and index the
    maximum award to inflation plus 1 percentage point, would result in a
    $10.4 billion or 57 percent increase in Pell Grant assistance from the
    2008-09 school year to the 2010-2011 school year. And the number of
    Pell Grant recipients would rise by nearly 1.5 million, or 24 percent,
    over the same period.
        We would be able to provide these dramatic increases in student aid
    in part because our proposal to use Federal capital to make all new
    loans through the Direct Loan program, along with our proposed
    restructuring of the Perkins Loans program, would save an estimated
    $24.3 billion over the next 5 years. This is an extraordinary
    opportunity to reform obsolete programs; increase aid available to
    students; and simplify the administration of student loans for
    students, families, schools, and the Department. In short, it is an
    opportunity that should not be missed.
        Finally, our 2010 request would launch a 5-year $2.5 billion Access
    and Completion Incentive Fund that would support innovative State
    efforts to improve college completion rates for low-income students.
    This Federal-State partnership builds on ideas Congress included in the
    Higher Education Opportunity Act, such as the State Grants for Access
    and Persistence program designed to complement LEAP. A key goal of this
    program is to learn more about what works, and what doesn't work, in
    improving student persistence to degree. The administration also
    intends to reach out to the philanthropic community as potential
    partners, and expects to make use of the Experimental Sites authority
    that we already have, to issue regulatory waivers for the purpose of
    research on programs to improve persistence.
                                   conclusion
        The Recovery Act provided unprecedented levels of Federal support
    for our schools in return for a commitment to meaningful reform
    strategies. President Obama and I believe that the Recovery Act has
    created a historic opportunity to improve the quality of our education
    system, and we are determined to make the most of that opportunity. Our
    2010 budget request would build on the resources and reforms in the
    Recovery Act to help create a public school system that prepares more
    students for the opportunities provided by a college education and
    helps ensure that they can afford to take advantage of those
    opportunities. As I said at the beginning of my testimony, I believe
    these are goals we all can agree on, and I urge you to support the
    President's fiscal year 2010 request for education.
        I will be happy to take any questions you may have.

                     PELL GRANTS AND COLLEGE ACCESSIBILITY

        Senator Harkin. Thank you very much, Mr. Secretary. That's
    a pretty awesome list of investments that you're making in
    education. I just, off the top, might say that on the issue of
    the Pell grants, well, I guess we are just going to have to
    discuss that further. I think there may be a little bit of
    concern here on this subcommittee and others about making that
    a mandatory program, but it's open for discussion. I don't have
    a closed mind on it, but I think there are reasons on both
    sides.
        Secretary Duncan. I look forward to the discussion, and we
    are open to that. The thing, just, that I worry about a lot,
    Mr. Chairman, is that I worry about fifth and sixth and seventh
    graders who are really smart, and who because dad or mom is
    losing their job, or taking a huge pay cut, start to think
    college is not for them, and that they won't be able to afford
    it. And what I really want is for those young students to know
    that regardless of how tough things are at home, that they are
    going to have an opportunity down the road, if they work hard.
        I worry about the psychological impact, where families are
    under tremendous financial stress, of children just thinking,
    ``College is not for me.'' And those dreams start to die at an
    early age.
        So whatever we can do to signal to young children that
    whatever stress your family is under, if you work hard and you
    are committed, you're going to have an opportunity to go to
    college--that's what is important to me.
        Senator Harkin. Well, I am glad to hear you say that.
    That's true. And you are saying that by making it mandatory
    that they have heard that. But there are a lot of other ways
    that we could be looking at, perhaps, making sure that students
    have access to college at any early age, as long as they study
    and get good grades. I am sure you have some ideas of your own
    about changing that system--about providing incentives to kids
    early on so that they can keep up their grades and keep up the
    work, that they get scholarships and they get access to
    college. But we will discuss that. As I said, I don't have a
    closed mind on it, but there are arguments on both sides of
    that.

                              TITLE I FUNDING GAP

        I want to cover my time a little bit on a couple issues you
    raised. One, on the Title I Program. Of course, we did put a
    lot in there, as you mentioned, in the Recovery Act, $10
    billion. So for this year and next year, things are fine. But
    obviously we are looking at what happens when the Recovery
    funds are spent--now in your budget, you requested about a $1.5
    billion cut.
        Well, you can say that's okay since we have all this money
    in the Recovery Act. But the problem with that is you cut the
    base. And you said that we are going to resume a commitment to
    this funding after the Recovery Act money runs out.
        But if we cut the base this year, then as we move into next
    year, you've got to make that up, plus an increase. And that's
    what I am concerned about is cutting the baseline.

               TARGETING TITLE I FUNDS TO LOWER THE DROPOUT RATE

        Secretary Duncan. Yes. I hear the concern. And what we are
    trying to do is really focus that title I money on title I
    children, particularly those schools that have historically
    struggled.
        As I mentioned in the beginning, I worry tremendously about
    our national dropout rate. It's a 30 percent dropout rate. And
    there was a time in our country, you know, a couple decades
    ago, when that was an acceptable dropout rate. There were jobs
    out there for students who didn't have a high school diploma.
    But as all of you know so well, today there are no good jobs
    out there for people without a minimum of a high school
    diploma.
        When we look at the high school dropout problem, it's
    fascinating. Again, a 30 percent rate. We have these 2,000
    dropout factories, about half are in urban areas, 20 percent in
    rural, 30 percent in suburban. So this is a national issue.
    This isn't one or the other. And we can identify 2,000 high
    schools that are producing half of our Nation's dropouts. Half
    the total, and 75 percent are minority students who drop out
    from 2,000 high schools.
        And the cost to our economy is just absolutely devastating,
    as is the loss of human potential. So what I want to do is
    target that title I money to really take this challenge on and
    not just keep perpetuating the status quo.
        Senator Harkin. And that's fine. I am concerned about
    making up the gap for next year. Now you've got to come back
    here again next year with the budget for fiscal year 2011, and
    I am concerned how you make up that $1.5 billion--I don't know
    that we are going to have any better allocation next year than
    we have had this year, and how do we make up that gap of $1.5
    billion, because we cut the base. So we are in a bit of a
    quandary there, and I just--when you say resume, would you look
    next year at bringing it back up to the 2009 level or would it
    go higher than that? I mean, I am just trying to figure out
    where we are headed on this.
        Secretary Duncan. Well, I think those commitments are
    really important to me, so how we do it is obviously not the
    question. I don't know yet, but I want to get those numbers
    back up and keep them up.
        Senator Harkin. Fair enough. We are concerned about that
    cut in the base.
        Secretary Duncan. Yes.

               IMPROVING EDUCATION FOR STUDENTS WITH DISABILITIES

        Senator Harkin. Students with disabilities, this is one
    that we pay special attention to. And we have done well, of
    course, in the Recovery Act with this money. It's an historic
    increase. But I am concerned about something that predates you.
    In 2004, reauthorization of IDEA, there was an allowance that a
    school district could reduce its special education expenditures
    by 50 percent of the increase--whatever the increase they got,
    they could reduce it by 50 percent over what they received in
    the prior year and spend those funds on any other purpose
    authorized in the Elementary and Secondary Education Act.
        Now, if a school has fulfilled all of its responsibilities
    to kids with disabilities and is meeting their needs, then I
    could see that might be fine for them to do that. But in all of
    the information that we have received, and the things that we
    have looked at, obviously some schools have done that, but a
    lot of schools haven't. And if they haven't met the basic needs
    of kids with disabilities, then I am concerned that if they
    take that money out, the students won't get the services they
    need.
        So I guess I would just say how--tell me again how your
    Department is supporting the effective use of the Recovery Act
    money to improve the education outcomes of students with
    disabilities and will you ensure the school districts are
    effectively meeting the needs of these kids before they are
    allowed to shift that IDEA money?
        Secretary Duncan. Very simply, I am in absolute agreement
    with you. And so where States or districts are in compliance,
    we will give them flexibility. Where States are out of
    compliance, we will not give them that flexibility.

                  DROP OUT RATE OF STUDENTS WITH DISABILITIES

        Senator Harkin. Right on. Thank you very much. I appreciate
    that very much. Again, when we talk about dropout rates, kids
    with disabilities, right now, are dropping out at a much higher
    rate, and a lot of this for just lack of supporting services
    for these kids at school. Almost 34 percent leave school early,
    and 52 percent of kids with disabilities complete high school.
    So again, I appreciate your response on that.
        I see that my time is out.

                            EARLY LEARNING PROGRAMS

        Senator Cochran. Mr. Chairman, thank you very much. Mr.
    Secretary, the budget requests $300 million for the new early
    challenge program, providing grants for the development of
    statewide programs for children from birth through age 5. Some
    States don't have pre-school programs in place, like my State.
    Would States like Mississippi be eligible for funding under
    this program in some fashion?
        Secretary Duncan. They would be and let me explain how, and
    obviously, we think this investment in early childhood is--you
    could make a pretty good case that it is the best investment
    any of us can make, so we are strongly encouraging it.
        So what we are looking for from States like Mississippi,
    that haven't historically invested, is they can use the
    stimulus dollars, and they can use title I dollars to do that,
    and then we can match those resources. So with all the
    resources coming Mississippi's way, if they invest that in
    early childhood, that would count as a match.
        So there is an absolute opportunity there, but we want the
    States to start to invest in early childhood. The State needs
    it, the country needs it.

                   INCREASING THE HIGH SCHOOL GRADUATION RATE

        Senator Cochran. In some States, dropout rates are
    declining. I think in our State they are coming down. But most
    recent statistics seem to indicate that too many students still
    do not complete high school.
        At what age was your program, again, under the new High
    School Graduation Initiative?
        Secretary Duncan. That's a great question. I would argue
    that it's not one age. The folks in early childhood are helping
    to prevent that, but that's long term. So I don't think there
    is one magical age to stop. If you can start with 1 and 2 and 3
    and 4-year-olds, that's the best. You know, prevention is a lot
    better than addressing the back end.
        So I would argue that every investment that we are making
    helps, from early childhood to getting the best teachers to
    work in the toughest communities, to thinking about turning
    around schools, to making college more accessible and
    affordable, and we haven't talked about raising standards that
    we are pushing very hard on.
        I would argue that everything that we are trying to do is
    with a single-minded goal of having more students graduate from
    high school, and having more of those graduates prepare to be
    successful, both in college and in the world of work.
        So I wouldn't give you one age, because I think you have to
    have a comprehensive approach.

                      PROPOSED MOVE TO ALL DIRECT LENDING

        Senator Cochran. The budget also proposes that all new
    postsecondary student loans originate and be serviced through
    the direct lending program. How do we pay for this entitlement
    program and ensure that students will not have their maximum
    grant reduced?
        Secretary Duncan. This is one that I think, again, we can
    pay for without asking for any more money from taxpayers
    because we will basically--again, this is controversial and not
    everyone agrees--but we will get out of the business of
    subsidizing banks. We are going to put all of that money into
    students who are in high school and going on to higher
    education.
        So this is a program that would generate savings,
    conservatively estimated at more than $4 billion annually,
    every single year.
        And so this is one where we can dramatically increase
    access for students, and do it without going back to taxpayers,
    and do it more efficiently. And this is not, sort of, a big
    Government idea. We want and we have to have dramatic private
    sector involvement on the servicing of those loans. We don't
    want to be in that business. We can't be in that business. So
    this is a real chance for the private sector to play, and we
    will reward those players who do a great job in servicing those
    loans.
        Senator Cochran. Let me wish you well and assure you that
    on both sides of the aisle on this subcommittee, we are
    interested in improving opportunities in education for all
    students, whatever their financial situation is, or whatever
    State they come from. And like States like mine, where we have
    had to struggle over the years to meet the educational needs of
    elementary and secondary students, that still is an area that
    cries out for support and assistance from the Federal
    Government. And I can remember, we used to in my State, it was
    kind of you didn't want the Federal Government coming in and
    taking over our schools, and telling us how to teach and all
    the rest, but the fact of the matter is, a lot of these
    programs have been very valuable.
        My mother spent a career in title I mathematics education,
    and was a supervisor for schools. My father was a county
    superintendent of education in the largest elementary and
    secondary school district in the State of Mississippi. I have
    observed at close range all of the challenges that face
    educators and students, alike, in States where there just
    doesn't seem to be enough money to go around and meet all of
    the needs that exist.
        So we appreciate your efforts and your support for States
    like mine.

                        SAVINGS FROM ALL DIRECT LENDING

        Secretary Duncan. I appreciate your comments. I look
    forward to working with you.
        Senator Harkin. Thank you, Senator. I might just add, CBO
    gave an estimate of $96 billion over 10 years, so you might
    want to talk to Mr. Orzag.
        Secretary Duncan. I will try to--I was talking to Tom
    Skelly----
        Senator Harkin. There is Mr. Skelly here.
        Secretary Duncan. Again, I talked about a minimum of $4
    billion and maybe well north of that.
        Senator Harkin. I should have introduced for the record,
    Thomas Skelly, your Budget Director for the Department of
    Education. Welcome back to the subcommittee, again, Mr. Skelly.
        Secretary Duncan. He is the brains of the organization.
        Senator Harkin. Yes. We have met him before. Senator
    Murray.

                 PARTNERING SCHOOL PROGRAMS WITH BUSINESS NEEDS

        Senator Murray. Thank you, very much, Mr. Chairman. I
    mentioned in my opening remarks my focus on making sure that
    the skills that we are teaching in our schools actually match
    what our businesses need. And I often hear from employers in my
    State, whether it's our high-tech, clean-energy companies or
    whether it's our boat builders and our construction workers,
    that the skills don't match between what our students are
    learning and what they need in their jobs. And I think we have
    to bridge that gap and as I told you, I will be shortly
    introducing legislation, again, to bring together all the
    players: the employers to the schools to the community; leaders
    to labor; and business workforce experts to design programs for
    their own communities, to focus on the employers and the skills
    that are needed in their own communities.
        And I wanted to ask you if you see a place in your budget
    for promoting those kinds of partnerships for the local level?

                COMMUNITY COLLEGE ROLE--ACADEMIC AND JOB SKILLS

        Secretary Duncan. That's hugely important. I would also
    say, which we didn't talk enough about, I think the community
    colleges play a huge role in this, sort of, trajectory of
    education continuum and I think that's been a really
    underutilized, undervalued resource. And whether it's high tech
    jobs or green jobs or healthcare jobs or jobs specific to your
    area--such as boat building. I was in Miami, and there's a
    fashion industry there. There is a huge player that I am
    actually trying to bring in, my under secretary, she was a
    phenomenal junior college president. I understand there's never
    been a community college president at that level of our
    organization. We think that's strategic. I think it's so
    important that we begin preparing our students for real jobs
    and building those pipelines and working very closely with
    those multiple partnerships. In some places you see great,
    great progress and in some places you don't. But whatever we
    can do to make sure that those employers are actually helping
    to shape the curriculum and helping to shape the opportunities
    that our high school students, as well as our community college
    students, have. We can't do enough of that. We have to tie
    education to the real world.

                                 PERKINS LOANS

        Senator Murray. And we have to look at funding programs
    that are already there. Then you've got Carl Perkins loans that
    were level-funded in your budget. Is there any chance for
    improving funding in that?

                             SCALING UP WHAT WORKS

        Secretary Duncan. Again, we have an opportunity not just
    to--this is a real chance for folks to be creative. In the $4.3
    billion Race To The Top Fund, it's all about investing and
    scaling up what works. The $650 million What Works and
    Innovation Fund is a chance for nonprofits and local players
    that partner with districts. So there is a huge chance that
    where we have demonstrated partnerships that will lead to
    higher student achievement, for us to invest in them at
    unprecedented levels and do more of what's working, that's with
    those pools of money.

                             TEACHER INCENTIVE FUND

        Senator Murray. I look forward to further conversations
    with you on that. You mentioned in your remarks to literacy and
    Striving Readers Act, which I introduced with Senator Sessions
    and I wanted to make sure that--I am not sure about my time. I
    want to ask you another question. But I would like to have an
    opportunity to talk to you in the future about that, and how
    you are going to include both adolescent and early literacy
    grants in the proposal, but with the few minutes I have left, I
    did want to ask you about the proposal for the Teacher
    Incentive Fund.
        It's a very large increase that you've asked for and it's
    going to grow the program five times the funding it currently
    receives to about $520 million. That program already received
    an additional $200 million this year in stimulus funds.
        Now this administration often has stressed to us the
    importance to implementing reforms that we know and can prove
    are effective. So can you tell me what the research base is,
    where it shows the effectiveness for the incentives for
    teachers, that justify an expanse for growth in that program at
    such a high rate?
        Secretary Duncan. It's a great question. There are two
    themes that I am going to keep coming back to. One I talked
    about is time. We need more time with our students. The school
    day, the school week, the school year is too short.
        The second one I fundamentally believe is we have to invest
    more in our teachers. And there is a tremendous body of
    research that great teachers, great principals matter
    tremendously. And there are studies that I have seen that talk
    about where the average student has three great teachers in a
    row, that child is a 1 \1/2\ to 2 years ahead of grade level.
    The average child that has three poor teachers in a row can be
    so far behind that it's hard for them to catch up.

                        FOCUS OF TEACHER INCENTIVE FUND

        So I worry a lot about--we talk a lot about the achievement
    gap. I am more interested in what I call the opportunity gap,
    of how we get the best and brightest educators.
        Senator Murray. Yes. I don't think anybody at all disagrees
    with the goal. I am just asking if you can provide us with some
    studies that show that the incentives actually are what makes
    those core teachers better.
        Secretary Duncan. I would be happy to do that. It's not
    just making core teachers better. That's why I was trying to go
    to the next step. What it does is, we want to create incentives
    for the best teachers to go into the most underserved
    communities.
        Senator Murray. So that's the focus of the program?
        Secretary Duncan. That's a piece of it. It's both
    developing talent and creating incentives. And I can just say
    from personal experience, in Chicago, where we did this, we
    only put this program in hard-to-staff schools that had
    significant turnover, and we only put the program into schools
    where 75 percent or more of the teachers asked for it.
        Senator Murray. Okay. Can you explain to me that you put a
    significant amount of money forward that has not been through
    authorization, can you tell me what safeguards are going to be
    in there against some subjective awards, or awards that are
    only based on test scores since you are putting this money out
    there?
        Secretary Duncan. Absolutely. We can sit down and walk
    through it very, very carefully with you. And in any good
    program, test scores are never the only thing you evaluate.

                   TEACHER INCENTIVE FUND COMPETITIVE GRANTS

        Senator Murray. My concern is that the program that goes
    out to the States, so it sounds good when you say it to us, I
    just want to know how it's going to be implemented?
        Secretary Duncan. Let me be clear. The money is not going
    out to the States. This is going out on a competitive grant
    basis, so folks are going to have to apply to us. So we can
    walk through with you what our request for proposal is going to
    look like and what our criteria will be for evaluating those
    proposals.
        So this is not money that is going to go out willy-nilly.
    We want to invest in those places that we think are doing this
    the right way. We would be happy to sort of walk through----
        Senator Murray [continuing]. It's not just going to be test
    scores and----
        Secretary Duncan [continuing]. Again, that never--let me be
    clear on two things. One, it can never just be about test
    scores. Second, it cannot pit teachers against each other.
        Senator Murray. Okay. So I would like to, at some point,
    work through it with you so I understand how that is going to
    work.
        Secretary Duncan. Absolutely.
        Senator Harkin. Senator Landrieu.

                                 SCHOOL REFORM

        Senator Landrieu. Thank you. Mr. Secretary, I just can't
    tell you how encouraged I am by what I have heard this morning.
    I just really believe you are the right person to lead this
    effort, and I am so encouraged with President Obama's continued
    focus, amidst all the other things that he's got to do, but he
    comes across to me and to many of us as just unrelenting, which
    is the way I think he should be, and obviously you are, on
    reforming a school system in crisis. And reforming a school
    system that is in such a state right now that is it unable to
    support the economic growth of this Nation. And the bold vision
    that you have outlined, I generally support, and I want to let
    you know that.

                                CHARTER SCHOOLS

        I have a comment though, if you could take a minute to
    explain to me and to the subcommittee a little bit about why
    the President's and First Lady's first visit, they stopped at
    charter schools. What is it that they see that we need to know
    about? Because there are some questions, as you know, about
    this issue around the country. We have had very good
    experiences with what we call independent public schools. But
    tell us for a minute about why you and the President feel so
    strongly about this direction.
        Secretary Duncan. It's a piece of the answer. It's not the
    answer. This budget, we didn't mention, includes an additional
    $52 million for charter schools. Let me tell you what we need.
    We don't need more charters, we need more good schools in this
    country. And for charters to be good, I think three things have
    to happen.
        First, you have to have a very high barrier to entry. This
    is not let 1,000 flowers bloom. And if you do that, you just
    perpetuate the status quo. So, you only pick the best of the
    best to open schools. That's like a sacred obligation, a chance
    to educate children. That should not go to everybody. That
    should go to the small percentage, the absolute best.
        Second, after you set that high bar, you need to give these
    educators real autonomy. These are by definition entrepreneurs
    and innovators. And you need to give them room and freedom from
    bureaucracy.
        Finally, you need to tie that real autonomy with real
    accountability. You have to have performance contracts.
    Obviously I am a big fan of charter schools, but I closed three
    for academic failure.
        And so I think if you have just autonomy without
    accountability, you don't get there. If you just have the
    accountability without the autonomy, nobody would want to play.
    So you need to get those three conditions, and that doesn't
    happen that way all around the country. I think you guys are
    doing a great job of it in Louisiana and New Orleans. But when
    those three things happen, you generally have some very high-
    performing schools in some of the most underserved communities
    in our country--inner city, urban, and rural.
        And so I think that it is not, by any means, the answer,
    but when done well and when done right, thoughtfully and
    strategically, it is a piece of the answer. And I think what is
    going on in your State, and New Orleans, specifically, is a
    fascinating example of what's possible when things are done the
    right way.

                EARLY CHILDHOOD EDUCATION AND SPECIAL EDUCATION

        Senator Landrieu. Thank you. My second question is about
    the disability issue and program, and Senator Harkin is such an
    extraordinary leader, and I try to be supportive where I can
    be, but I want to just share from my experience, Mr. Chairman,
    as the chairman of the D.C. subcommittee at some point. We
    looked into the disability, the cost of the disability program
    here in the District. And my staff is going to be getting me
    some specific numbers for the record, but I believe, if my
    memory serves me correctly, that the cost per student here is
    somewhere between $20,000 and $40,000 a year. Is that your
    understanding of the students in the District that are going to
    outside of the public system? And Mr. Skelly, do you know what
    the numbers are?
        Mr. Skelly. Senator, those numbers sound about right, but I
    am not aware of them specifically.
        Senator Landrieu. I am going to ask the staff to get those
    numbers on the record, because the point that I am making here
    is that if we don't get on the front end of this situation,
    which is, I think, what your budget is attempting to do, which
    is investing in early childhood education, keeping children,
    Mr. Chairman, from getting an inappropriate and unnecessary
    label as dysfunctional just because they can't read. And then
    they get into a trap that is actually unsustainable for any
    budget to continue. It's a totally different issue than trying
    to provide basic services, which the Chairman on our committee
    will insist be given.
        So I just want to lay the record down that we need to find
    those numbers out, because it's unsustainable at the $20,000 to
    $25,000 a year.

                      READING SKILLS AND SPECIAL EDUCATION

        Secretary Duncan. I would argue that in many places, it's
    much higher than that. And as you know, so many children go
    into special education because they are labeled LD, learning
    disabled----
        Senator Landrieu [continuing]. A lot of times they can't
    read----
        Secretary Duncan [continuing]. And that means they can't
    read. So if we teach our children to read, they don't go into
    special education. And what's amazing to me is you almost never
    see anyone exit special education. Once you go in, in many
    cases, you are there forever. And so the right thing to do is
    to do a much better job on the front end, and it is right for
    multiple reasons, but if we could have--if we could reduce over
    time the numbers who are going into special education because
    they can't read, we will be doing those children a tremendous
    service.
        Senator Landrieu. Thank you, Mr. Secretary.
        Senator Harkin. Thank you, Senator. Senator Kohl.

                              HIGH SCHOOL DROPOUTS

        Senator Kohl. Thank you, Mr. Chairman. Mr. Secretary, as
    you sit here this morning, one of the most urgent crises that
    we face is the epidemic of high school dropouts and the fact
    that No Child Left Behind did not do very much to address this
    problem.

                     DUAL ENROLLMENT PROGRAMS AND DROPOUTS

        Many ideas are proposed to increase high school graduation
    rates and better prepare our students for college. I have been
    talking about additional Federal support for what they call
    dual enrollment programs to help low-income students get on a
    fast track to get a high school as well as a college degree.
        As you know, these programs help students. They save time
    and money on college courses while building the skills and
    confidence they need to succeed in the college environment. The
    President has expressed his efforts to help high school
    students begin earning college credits.
        Do you anticipate increased support for early college and
    dual enrollment programs?

                      BENEFITS OF DUAL ENROLLMENT PROGRAMS

        Secretary Duncan. Senator Kohl, I am very familiar with
    that work under your leadership, and I want you to know how
    much I appreciate it. It does a couple things for students, and
    I will tell you how we will support it, but let me tell you why
    I think it's so important.
        First of all, in these tough economic times, having
    students get that college credit in their back pocket before
    they go on to college will save the high school student
    significant money.
        The second thing it does, which I think is probably more
    important, particularly for children who might be first
    generation going to college, and English language learners, it
    helps them really understand in their heart, that they can be
    successful at the college level. They really can do it. Some of
    these children reach a psychological barrier, that they are
    academically prepared, but because they don't have family
    members who have taken that step, they don't believe they can
    do it. And when they have that dual enrollment or dual credit
    system as a 10th, 11th, 12th grader, they know they can be
    successful at that collegiate level.
        So there is a huge opportunity in both the $4.35 billion
    Race to the Top Fund for States, as well as the $650 million
    Innovation Fund for districts, community colleges,
    universities, cities, whatever it might be, to come together
    and expand upon those programs that are working. I think that's
    a very significant investment.
        Senator Kohl. In terms of priority, the program seems to me
    should have a very high priority, if we talk about encouraging
    our high school students that aspire to going to college, and
    to more than talk about it, to give them a way in which they
    can start down that path.
        What kind of a priority do you have on that?
        Secretary Duncan. Dual enrollment is one of our FIPSE
    competitive priorities in fiscal year 2010.

                           INCENTIVE PAY FOR TEACHERS

        Senator Kohl. Thank you. On the teacher incentive fund and
    merit pay, during your time in Chicago, how did you work with
    teachers and unions to get this kind of a system up and going
    and implemented? What did you learn?
        Secretary Duncan. As I said, the only way--I know Senator
    Murray has some concerns, so I should have addressed this more
    clearly while she was here, the only way this works is when you
    do it in collaboration. And actually what we did in Chicago, is
    we had a set of the best teachers in the system who started an
    advisory council for me, they actually set the program up. So
    it was absolutely teacher led.
        They figured it out. They went out and met with schools
    around the city and they applied for the grant through the
    Department of Education and did a phenomenal job. I think we
    were awarded the largest grant in the country.
        And it's interesting. You do all this hard work, and you
    think you have a good idea, but at the end of the day, you
    don't know if anyone is going to be interested. We had 120
    schools show interest and we would only go to schools where 75
    percent of the teachers wanted the program. And at most of the
    schools we picked, 95, 98, 100 percent of the teachers asked
    for it.
        So this is driven by great, great teachers. They want to be
    rewarded. They want that excellence, to shine a spotlight on
    that, and they want to get more great teachers into underserved
    communities. So this is a perfect opportunity for
    collaboration. And there can be tough conversations or
    differences of opinion, and that's part of the process. But the
    program we did in Chicago was created and established and led
    by a set of the best teachers in the city.

            ADDRESSING IMMEDIATE FISCAL NEEDS AND SUSTAINABLE REFORM

        Senator Kohl. Good. As you know, the Recovery Act passed by
    Congress contains billions of dollars for one-time funding for
    public schools. In many States, such as my own State, they are
    facing serious budget constraints and struggling just to
    preserve jobs and maintain existing education services. As you
    administer the funds provided in the Recovery package, how will
    you help States invest in sustainable improvements while also
    addressing their immediate fiscal concerns?
        Secretary Duncan. Right, and sometimes people can see that
    as a tension, and I think this is a real test of leadership and
    creativity. So it is, you know, times of crisis that provide us
    a huge opportunity. We have to be thinking about both. Let me
    give you an example, on the IDEA funding, unprecedented
    resources, how can you spend that money wisely? I would argue
    that one of the best things that we can do is invest a massive
    amount of money and train all teachers how to better work with
    special education teachers. I think we have had this divide
    between special education teachers and regular teachers, and
    the fact of the matter is so many of our regular education
    teachers have special education students in their classroom,
    and don't know how to do a good job with them. And so I think
    that's one area where the benefits for those teachers and
    school systems will far outlast the availability of those
    funds.
        And so we want to work very, very hard. You see, again, I
    talk a lot about time. You know, thinking differently about
    time. You see lots of school districts trying to figure out how
    to do more over the summer, more on the weekends, more on
    Saturdays, and bring in nonprofit partners and build
    sustainable programs, where schools are open 12, 13, 14 hours a
    day. Where the money can be a catalyst by bringing in all these
    outside partners, you have a huge leverage on those resources.
        So we are going to continue to provide guidance. We are
    going to highlight examples of success, like Cincinnati, that
    added what they call a fifth quarter, this summer, now, for
    their students, keeping them a month longer after the school
    year ends. We are going to continue to provide those kinds of
    best practices as examples for folks around the country.

                               PREPARED STATEMENT

        And, you will see some real innovation. And you will see
    some folks that are paralyzed by the crisis, and this will be a
    real test of how leadership handles a tough situation and an
    opportunity, and I would argue that the nexus of crisis and
    opportunity gives a huge chance to push for the kind of
    dramatic change we need.
        [The statement follows:]
                    Prepared Statement of Senator Herb Kohl
        Thank you, Mr. Chairman. Mr. Duncan, I join my colleagues in
    welcoming you here today. I appreciate the difficult task you face in
    improving our public education system, particularly in light of the
    fiscal constraints we face during this recession. As we seek to
    maintain America's competitiveness in the global economy and guarantee
    our children their chance at the American Dream, I believe your task is
    more important than ever.
        As you know, one of the first orders of business must be to reform
    and reauthorize the Elementary and Secondary Education Act, currently
    known as No Child Left Behind. I initially supported this legislation
    because it guaranteed increased Federal funding and flexibility in
    exchange for real accountability from schools. However, over the years,
    funding levels have fallen billions short of what was authorized, and
    schools are struggling to meet the law's requirements without the
    necessary resources and evidence-based solutions to meet ongoing
    challenges. To make matters worse, Congress also has not provided the
    funding promised to States for special education under the Individuals
    with Disabilities Education Act. This chronic underfunding of our
    public schools has caused serious hardships nationwide and makes it
    extremely difficult for teachers and students to meet their goals.
        I am hopeful that President Obama and this Congress will make
    school funding one of our Nation's highest priorities. Although the
    current economic crisis requires fiscal prudence, I believe education
    is one of the best investments our Nation can make to ensure future
    economic growth and stability. I am also hopeful that, under your new
    leadership, the Department of Education will use Federal funding to
    foster innovative ideas and new policy solutions to ensure that all
    students have the opportunity to fulfill their potential--regardless of
    the State or neighborhood in which they live. I look forward to working
    with you and the President as we work toward these important goals.

        Senator Kohl. Thank you so much. Thank you, Mr. Chairman.
        Senator Harkin. Thank you Senator Kohl. We call Senator
    Pryor.

                        STATEMENT OF SENATOR MARK PRYOR

        Senator Pryor. Thank you, Mr. Chairman. And Mr. Secretary,
    thank you for being here. I first want to start on the stimulus
    spending and say that the feedback from the Arkansas Department
    of Education and educators in our State are very positive on
    that and we appreciate your help and your Department's
    cooperation and assistance. And I am sure a lot of other States
    have had that same experience, and we want to thank you for
    that.
        Secretary Duncan. We will try and keep it that way. Just
    one plug for our staff. They have done a phenomenal job. Folks
    are applying, and we are committed to turning around the
    applications in 14 days, and we have been doing it in 6. Our
    staff is working nights and weekends and I couldn't be more
    proud of their collective effort.
        Senator Pryor. That's very un-Federal and un-Government
    like, and that's good.
        Let me also mention just one concern, and that is, our
    State Department of Education has put a lot of requirements and
    very stringent guidelines on the money to make sure it is going
    to the right places and doing the right things. And we
    understand that there is going to be an audit of that, and
    that's great. Everybody should welcome that. But the only thing
    is that I would ask, that your Department coordinate with our
    State departments around the country to make sure that we are
    auditing the same things, and that we are focused on the same
    things.
        Secretary Duncan. I would be happy to go over that with
    you. With unprecedented resources you want to have
    unprecedented transparency and real clarity and visibility to
    see how every single dollar is being spent.
        Senator Pryor. Right.
        Secretary Duncan. And as much as we coordinate and work
    together, and not waste and not overload and not duplicate
    resources, that makes a lot of sense.

                         ADDRESSING THE DROPOUT PROBLEM

        Senator Pryor. Exactly. Thank you very much for that. I
    also want to follow up on something that Senator Cochran
    mentioned earlier about dropouts and how that has been a real
    challenge for the Nation, and you mentioned about the drag on
    the economy and problems that that causes long term. I think
    you guys have set aside, what, $50 million for a new high
    school graduation initiative, and how did you arrive at that
    figure and how do you envision that money being spent on that?
        Secretary Duncan. That is a piece of the money, again, I
    would mention the $5 billion school improvement entitlement
    money that we really want to focus on this. And I think as a
    country, we have shied away from the complexity of this and the
    difficulties of this, and I think we do that at great detriment
    to those children, and at great harm to our Nation's economy
    long term. So I want to confront this front and center.
        And again, when you look at the data, it's fascinating. The
    economic costs are staggering. When we think about 2,000 high
    schools producing half the Nation's dropouts, and 75 percent of
    the dropouts are minority children, that's a number you can get
    your hands around. You can't tackle every school tomorrow, but
    if we could systemically, year after year, come back and do
    something dramatically better, not just for those high schools,
    but those feeder elementaries as well, I think we could turn
    this around.
        And what we have, why I am optimistic, is we have in every
    rural community that's poor, and any inner city urban
    community, while we have these ``dropout factories'' we also
    have schools where 95 percent of students are graduating, and
    90 percent of those that graduated are going on to college. So
    we know what works. We know what is successful out there. There
    are more good examples out there today than ever before, and
    what we want to do is scale those up, invest in those best
    practices, and give more students those kinds of opportunities.
        So this is a tough battle, but it's absolutely the battle I
    think we need to fight and I am committed to being in it for
    the long haul.
        Senator Pryor. And it's another example of where the public
    schools, the apparent demographics of the population that we
    are serving presents a lot of unique challenges and
    circumstances around the country.

                               THE GRADUATES ACT

        Let me just let you know about something, if you don't
    already, and that is, last year, Senator Harry Reid and I had a
    bill, we called the Graduates Act, and basically what we were
    trying to do is come up with a way to incentivize and reward,
    innovative partnerships to try and keep people in school with
    the public and private sector. Are you familiar with that?

                       RAISING COLLEGE GRADUATION BY 2020

        Secretary Duncan. Yeah, and we want to build upon all
    those--everything we can do to have students not just graduate
    from high school, but go to college; but not just go, but
    graduate from college. We have to. That's what this work is
    about at the end of the day, to try to dramatically drive up
    our college graduates by 2020. We have to take steps every
    single year, and I appreciate your leadership in that effort.
        Senator Pryor. Well, I just--that was a little bit before
    your time, before you got here, and I just wanted to make sure
    you were aware of it.

                    SAFE AND DRUG-FREE SCHOOLS STATE GRANTS

        There are some grants that serve at-risk populations that
    the administration has eliminated or has proposed elimination
    of that deal with safe and drug-free schools. Could you talk a
    little bit about that?
        Secretary Duncan. I did. I talked about it in my statement.
    That what we saw was that money we put out--obviously those are
    big issues for me, both trying to keep our schools drug-free,
    but also dramatically reduce violence. We found through
    research and doing evaluation of this money that we put through
    the States, there wasn't much effectiveness there. But money we
    put out directly to districts and schools, we saw more
    effectiveness. So we basically eliminated the State grants and
    put an additional $100 million into a national program.
        So I was trying to be more strategic: same goals, same
    commitment. We are trying to be much more targeted in getting
    those resources where it needs to happen.
        Money was dribbling out to States, and we just weren't
    seeing in objective research, in evaluative studies, we weren't
    seeing the impact we want.
        Senator Pryor. Do you feel like you have good ways to
    measure that? Are you confident in your ability to measure
    that?
        Secretary Duncan. Yes, I am pretty confident we can measure
    that.
        Senator Pryor. Thank you, Mr. Chairman.
        Senator Harkin. Thank you, Senator Pryor. Senator Specter.
        Senator Specter. Thank you, Mr. Chairman. I join my
    colleagues, Secretary Duncan, in welcoming you here. You have
    taken on a tough job. I have had the opportunity to work on
    this subcommittee for many years, and it's very, very
    difficult.

                   PROPOSAL TO MOVE FFEL TO ALL DIRECT LOANS

        I would like to start by asking you about the Federal
    Family Education Loan Program, where the proposal has been made
    to have direct loans as of July 1, 2010 and questions have been
    raised in my State by the folks in the Pennsylvania Higher
    Education Assistance Agency as to whether that can be
    implemented in that length of time, and whether the allocation
    of funding set at $500 million per year would be adequate to
    take on the services which are currently provided, including
    early awareness, financial literacy training and counseling
    programs; and what will happen to the very substantial number
    of employees who are working for not-for-profit in public
    agencies in their State. So it is a sweeping change. No doubt
    this is a very important program, and necessary to keep young
    people in school, especially given the economic problems of
    today.
        How do you propose to address those very serious
    considerations?

                       SAVINGS FROM MOVE TO DIRECT LOANS

        Secretary Duncan. Yeah, so there are a couple pieces. First
    is by making that switch from FFEL to direct lending, we can
    dramatically increase the amount of money going out to students
    directly, you know, in Pell grants. So we are anticipating
    savings of over $4 billion a year, and at a time when going to
    college has never been more important, as you know, it's never
    been more expensive and families have never been under more
    financial duress.
        So we can sustain indefinitely, dramatically higher levels
    of funding for students without going back to taxpayers for
    another dollar. The $2.5 billion over 5 years, to help work on
    not just access, but on completion, actually significantly
    increases the amount of resources that will go out to
    nonprofits. It will help keep those students in school and
    build a culture at universities where it's not just about
    access, but it's about attainment, making sure students know
    what the opportunities are and in making sure they graduate.

                       LOAN SERVICING UNDER DIRECT LOANS

        So we think these are the right investments to make. On the
    servicing of loans, we don't want to get into that business.
    That is all going to be done by the private sector. We don't
    want to get into that. We have no expertise in it.

               PROGRAMS PROVIDING TRANSITION TO COLLEGE SERVICES

        Senator Specter. Mr. Secretary, how about programs that I
    stated and enumerated on: early awareness, financial literacy
    training, counseling programs, will they be maintained under
    the changed program?
        Secretary Duncan. I think more than maintain, we want to
    actually enhance. We want to do more than that.
        Senator Specter. Do you have more than the $500 million,
    which is currently allocated here?
        Secretary Duncan. Well, that's a starting point. I think
    that's a very significant investment and to be able to do that
    every year over the next 5 years gives us a huge opportunity to
    better inform and better help students understand what their
    options are.

                              IMPACT ON EMPLOYMENT

        Senator Specter. How about the large number of employees?
    Would there be some effort made to transition and accommodate
    the 2,200 employees who are in my State, and who are of great
    concern to me?
        Secretary Duncan. Well, again, it depends what business
    they're in--on that side, we think there will be a growing
    market. We are going to need more folks doing this work and we
    think we are actually going to increase the market share for
    the folks working on the servicing of loans. And so we are
    hopeful that the job loss will be minimal and we're actually
    going to create jobs in those two areas.

                                GEAR UP PROGRAM

        Senator Specter. Mr. Secretary, shifting to another
    program. There has been an operation called GEAR UP, which was
    originated by Congressman Fattah on the House side. And this
    subcommittee has provided very substantial funding of $300
    million a year and the program has been in existence for 7 or 8
    years now. So it has really taken off. And these are at-risk
    students, and they tie into efforts which this subcommittee has
    taken the lead on mentoring. So many single parent families,
    working mothers, children at loose ends, not afterschool care,
    and efforts have been made to find adult mentors in the
    community, this ties into many facets of their lives: the
    learning program, the delinquency issue, the crime problems,
    and I would be interested to know what thought you might have
    of your Department supplementing efforts now being undertaken.
        Secretary Duncan. I am a big fan of the GEAR UP program. We
    were a large beneficiary of that program in Chicago, and for
    all of the reasons you said, these are students who desperately
    need that help and need the chance to be supported in that
    transition from high school to college, and so we are going to
    support those efforts going forward.

                            IMPORTANCE OF MENTORING

        Senator Specter. How about the mentoring aspect?
        Secretary Duncan. That's hugely important. Our children
    need adults in their lives to help them to understand what
    their options are, and doing the hard work with them every
    single day to stay on track.
        Senator Specter. Thank you, Mr. Secretary. I'd appreciate
    it if I could have your commitment to take a personal look at
    how the Direct Loan program is going to go, to accommodate as
    best you can the kinds of concerns I have raised.
        Secretary Duncan. You have that, and I would be happy to
    sit down with you further and discuss exactly what's going on
    in your State.
        Senator Specter. Thank you.

                  BASIS FOR AWARDING LOAN SERVICING CONTRACTS

        Senator Harkin. I just want to echo a little bit what
    Senator Specter just said here. The last thing I want to see
    happen is to see Mr. Lord get more money to buy--to build more
    private golf courses for himself. You know, this whole scandal
    that happened at Sallie Mae was awful. If someone can make that
    much money off the back of students, that just shouldn't be
    allowed. Now again, because Sallie Mae has gotten so big,
    because of the subsidies that we have given to Sallie Mae over
    the years, now they are able to undercut everybody else. So, it
    does require some more looking into.
        If just the cost is the only basis on which we are going to
    award these service contracts, then Sallie Mae can undercut
    everybody. But, my gosh, we are the ones who gave them all
    these subsidies all these years so they could get that big.
        Secretary Duncan. It just can't be cost. It is going to be
    cost and ability to help those students.
        Senator Harkin. Exactly. I appreciate it.
        Secretary Duncan. You have to look at both.
        Senator Harkin. I appreciate that.
        Secretary Duncan. You have to look at outcomes.

                      SUSTAINING RECOVERY FUND INITIATIVES

        Senator Harkin. And outcomes, exactly right. Exactly, Mr.
    Secretary. Mr. Secretary, you mentioned Cincinnati has
    increased the school year by a month?
        Secretary Duncan. Yes.
        Senator Harkin. Well, that's pretty good. My question is
    where does the money come from?
        Secretary Duncan. The stimulus.
        Senator Harkin. Stimulus money? So what are they going to
    do when the stimulus money runs out?
        Secretary Duncan. Well, we will cross that bridge when we
    get there. But, this is the right thing to do for children now
    and it keeps students at-risk in school. It keeps teachers
    teaching. And what I would argue is that every dollar,
    historically, hasn't always been used really wisely, and you
    are going to see some innovation with stimulus dollars, and if
    these things work--I am very optimistic. Obviously we don't
    have any data yet, but what I would argue is if districts and
    States start to do some creative things with stimulus dollars,
    that might change their allocation and their strategic use of
    their dollars once that money is gone.

                               LONGER SCHOOL YEAR

        Senator Harkin. Don't misunderstand me. I happen to be one
    of those in favor of a longer school year. I think the school
    year ought to be 11 months.
        Secretary Duncan. Twelve.
        Senator Harkin. Well, I am all for giving them the month of
    August, 3 or 4 weeks in August, that would be fine. But I do
    believe that it should be longer. And we have got to get to
    that point. It is just not right what we are doing with these
    kids today.
        Secretary Duncan. And again, I think this is one bit where
    we have not had as much creativity as we need. And more and
    more, the data is showing this. And if we can use stimulus
    dollars as sort of the impetus to get this gain, I think folks
    will start to think about how they are using other resources
    and start to allocate more funding in this direction. But this
    opens that door, which I think is so important.
        Senator Harkin. Well, let's open the door further. I would,
    both on this subcommittee, as Chair of the subcommittee, but
    also on the authorizing committee, we ought to be saying what
    we can do over the next few years to expand that school year?
    We have got to do this. We just can't keep on like we are.
        Secretary Duncan. I appreciate your leadership on this
    issue. I think it's a big, big deal.
        Senator Harkin. I don't know if I am much leadership, but I
    got a lot of support for you. I can put you out there on the
    point, Mr. Secretary. We'll be right there backing you up.

                   RECOVERY ACT DISCRETIONARY EDUCATION FUNDS

        Let me ask you a little bit more about the Recovery Act. It
    provides that you get more money for discretion than any
    Secretary of Education has ever had. This is your money and you
    can just sort of do with it as you wish, $4.35 billion for the
    Race To The Top Fund, $650 million for What Works and
    Innovation Fund.

                           RACE TO THE TOP FUND GOALS

        Again, this can be powerful incentives. Again, we don't
    really have many details on what you plan to do with it. On the
    Race To The Top Fund, I mean, let's fast forward a few years. I
    mean, if we go ahead 5 years, what will you hope to have
    achieved, and how will we know if it has worked? What will be
    different in terms of what districts and States do in
    education?
        Give me some idea about this Race To The Top.
        Secretary Duncan. What we want to do--what I think,
    historically, what we have a bit is the race to the bottom. And
    that has really hurt our country and hurt our economy and hurt
    our children, and we want to fundamentally use these dollars to
    reverse that. And the Race To The Top means it's not by
    accident.
        What we want to do, let me take the $4.35 billion first and
    I will come back to the $650 million. On the $4.35 billion, we
    want to work with a set of States that are willing to lead the
    country where we believe we need to go. There are four areas we
    are looking at.

                            SETTING HIGHER STANDARDS

        One is we want to see higher standards. I have been arguing
    pretty vociferously that in too many States, due to political
    pressures, standards have been dummied down and watered down,
    and that in fact, we have been lying to children. Let me take 1
    minute on why I say that.
        When you tell a child that they are ``meeting a State
    standard,'' the logical assumption by that child and that
    parent is that child is on track to be successful.
        In far too many places, including the State I am from, from
    Illinois, those children who are ``meeting the standards'' are
    barely able to graduate from high school, and absolutely
    inadequately prepared to go to a competitive university, let
    alone graduate.
        So we want to talk about common, college-ready, career-
    ready, internationally benchmarked standards. Really raising
    the bar there.

                     DEVELOPING COMPREHENSIVE DATA SYSTEMS

        Second, we want to talk about comprehensive data systems,
    so that you can't lose children throughout the educational
    trajectory. You have to know how they are performing. You want
    to be able to track students to their teachers, to know which
    teachers are making the biggest difference in their students'
    lives, and you want to be able to track teachers back to their
    schools of education, so you can know which schools of
    education are producing the teachers, who are producing the
    students that are learning the most.

                              INVESTING IN TALENT

        Third, we want to invest deeply in talent. Great teaching,
    great principals matter tremendously. And how do we think about
    getting the best and the brightest to work in the communities
    that have been historically underserved--rural, inner city, and
    urban?
        We have had a shortage of math and science teachers for how
    long? A couple of decades? I would like to pay math and science
    teachers more. Some people disagree with me. I think we need to
    end that. And how can we create the next generation of
    engineers and mathematicians and people who are going to create
    the breakthrough technologies if they are not being taught by
    the teachers who know the content?
        So really working with States that are willing to think
    differently about talent, getting the best and the brightest
    where we need them, awarding excellence, thinking about areas
    of critical need.

                           HELPING STRUGGLING SCHOOLS

        And then finally, I keep coming back to this idea of
    struggling schools, and I want to take just 1 second on this.
    We have about 95,000 schools in our country. Let's call it
    100,000. What if we took the bottom 1 percent, the bottom 1
    percent of schools each year----
        Senator Harkin. You mean bottom in what way?
        Secretary Duncan. One thousand schools, dropout factories,
    low gain, students not learning, basically just simply not
    working; and we can figure out State-by-State what that would
    look like. What if we took their bottom 1 percent every year
    and just fundamentally turned them around? Stop tweaking around
    the edges, stop looking at incremental change, but really
    trying to attack this dropout program full, square on, at both
    the high school, middle school, and at the elementary level.
        What we want to do is look at those four reforms and work
    with a set of States and invest hundreds of millions of dollars
    in those States that are willing to lead the country where we
    need to go. This is really about having courage, and having the
    will to challenge the status quo in some areas.

                     RACE TO THE TOP--REQUEST FOR PROPOSALS

        So in the next 2 months or so, we will issue a request for
    proposal to States. We will look at how they are making
    progress against these things, and we want to have a set of
    States, again, lead the country and set an example of what is
    possible.
        On the $650 million, the Innovation Fund, investing in what
    works----
        Senator Harkin. Let me interrupt. So the request for
    proposals, when you put those out, and you are going to do that
    within the next month?
        Secretary Duncan. Two to three months. We want to be very
    thoughtful about it, so we are spending lots of time thinking
    about it now.
        Senator Harkin. Okay. So they will include specific areas
    of focus in the requests?
        Secretary Duncan. Yeah, and these echo and mirror the
    assurances we look for on the stimulus dollars, under the
    Recovery Act. These are the same areas. We are trying to be
    very, very consistent in our message. We ask States to make a
    series of assurances to receive stimulus dollars, and this RFP,
    this request for proposal, will mirror those same assurances.
    So we are trying, again, to be laser-like focused on those
    things that we think will make the biggest difference.

                            INVESTING IN INNOVATION

        Senator Harkin. Now the $650 million?
        Secretary Duncan. The $650 million is not focused on
    States. It's focused on districts and nonprofits. So this is
    trying to--again, we have so many districts and we have so many
    schools and we have so many nonprofits that are making huge
    differences in students' lives.
        For me, what's so helpful is that I don't think I have to
    come up with any great ideas. I think all of the great ideas
    are out there. We need to listen. We need to learn. We need to
    invest in what works and scale it up.
        And what our challenge is and opportunity, I think, Mr.
    Chairman, is this. We have these huge pockets of excellence. We
    have these islands of excellence. I want to take those to
    scale. If something is working, I want to give more students,
    more teachers, more communities the opportunity to benefit from
    that.
        We are seeing this flourishing of innovation in education
    over the past 10, 15 years. We have wonderful examples of what
    is happening, but they are all constrained by resources. If we
    can significantly invest in those and give more students, more
    teachers and more schools, more districts, more communities
    those kinds of opportunities, I just simply want to invest in
    what in those programs have demonstrated an ability to make a
    difference in students' lives. That's the purpose of this $650
    million.
        Senator Harkin. Thank you very much. I will come back to
    that, but first I want to yield to Senator Reed.

                      ACCESS AND COMPLETION INCENTIVE FUND

        Senator Reed. Thank you, very much, Mr. Chairman, and
    welcome Mr. Secretary. And let me first raise a question that I
    suggested in my opening comments. That is that the Access and
    Completion Incentive Fund is something that we are all excited
    about. In your own statement, you suggest that it is going to
    be built on some form of the LEAP and GAP program that we
    passed last year. And I wonder if you might go into some of the
    details, Mr. Secretary?
        Secretary Duncan. Yes. I think these are really
    complementary. What the LEAP--and this is your baby, so you
    well know that LEAP can help some States do more to create
    need-based aid, not just merit based, so really helping those
    students who are poor. And again, what I want to do is not just
    help give them access, I want to drive up completion rates. I
    want to work on attainment. So what these resources will do, it
    will go through States to universities, to really build a
    culture that helps those--probably help those very same
    students that your program is supporting--those students who
    come in, who may not have had family members who have gone to
    college, who might be English language learners, and so for me,
    the goal is not just about access. It's about completion. I
    think that these two, could actually be very, very
    complementary and mutually reinforcing.
        Senator Reed. Well, part of this whole process is making
    children aware, really, of their potential to go onto higher
    education, and also, to try and incentivize the State to put
    more money in what are very difficult times. So anything you
    could do to coordinate those programs, make them work in
    tandem, not just to get them there, as you said, both
    financially and academically.
        Secretary Duncan. It's really interesting, not to belabor
    the point, but as you well know, universities are actually, to
    me, a lot like high school. You have some high schools that do
    a great job on graduation rates, and some that don't. There are
    some colleges that do a great job in working with at-risk
    students and help them to graduate, and some don't. Again, we
    have to scale up those best practices. And I will tell you
    honestly, that we tracked this data very closely in Chicago,
    and we started to steer our graduates away from some
    universities, and towards others. Because as we looked at the
    data, we saw that some universities that would have--you know
    this type of population, this GPA, this class rank, this SAT
    score; 90 percent of those students were graduating, and at
    another university, 50 percent were. I mean, huge disparities
    from very similar populations.
        And so the more we can share those best practices, and get
    more universities thinking about this--you know, we have done
    very little to incentivize universities to graduate students.
    We give them lots of money to get students in the door, but we
    haven't done enough on the completion side. And that's where I
    want to continue to focus every single year.
        Senator Reed. Thank you. Let me turn the page literally to
    another issue, and that is I commend you for the economic
    recovery package, getting money out. As you pointed out in your
    opening statement, preserving employment and preserving
    opportunity for students in thousands of communities, both
    large and small, across the country.
        The first round was, essentially, to get the money out to
    plug gaps. And the second round, though, I think you are going
    to have to look closely at how that money has been spent, so
    that it is truly honed in on the objectives and the outcomes
    and the reform that you emphasized.
        Can you give us an indication of how you are going to look
    at the second round of funding, and tell what judgments you
    will make?
        Secretary Duncan. Sure. And it's a great question. We
    intentionally did not put out 100 percent of the money. We put
    out a lot because there was desperate need and we wanted to
    stave off this educational catastrophe. And again, coming from
    my previous job, you want to give States and districts the
    opportunity to plan for the upcoming school year and not have
    that uncertainty.
        You are exactly right. As we go into the second round, let
    me be clear, where States are doing the right thing, and being
    creative and innovative, that's right. And we will continue to
    support them.
        Where States have acted in bad faith, or are playing shell
    games or doing nothing, we have the ability to withhold that
    money.
        And further beyond that--so that's the stick. And we are
    prepared--don't want to use it--but we are prepared to use it
    if need be.
        And the second part of that--the carrot, as Mr. Chairman
    brought out, is that we have these unprecedented discretionary
    resources, you know, $4.35 billion Race To The Top, $650
    million Invest in What Works Innovation Fund. And I will tell
    you, States that are trying to game the system or are playing
    shell games or act in bad faith, they will basically eliminate
    themselves from those further competitions, and deprive their
    States of unprecedented new resources coming in.
        And so we are trying to work with both carrots and sticks
    to encourage States to do the right thing by their children.
        Senator Reed. Well, I think that's a very important message
    to get out today because States are under excruciating fiscal
    pressure. And the pressure to just get through the day is so
    excruciating that unless you lay down clear guidance and clear
    markers, from what you said today, I think that they will
    succumb to that.
        Secretary Duncan. Yeah. We are trying to be absolutely,
    explicitly clear. We will continue to do that, and again, we
    are not looking for a fight. But we are prepared to have that,
    if need be.
        This is too big of an opportunity for our Nation's school
    children to mess around.

                  IMPROVING LITERACY THROUGH SCHOOL LIBRARIES

        Senator Reed. Let me raise another issue, Mr. Secretary,
    and that is that with my colleagues, we work to improve school
    libraries, and not only just for the sake of the library, but
    for improving literacy. And we have had some very impressive
    results in terms of demonstrating increases in literacy. I know
    that the budget is rather slim, about $19 million, I think. The
    grants that have been put out, I think they were roughly 496
    applicants and only 60 were filled because of the budget
    limitations.
        And the other aspect to the legislation is that if we ever
    reach the $100 million mark, and it's a formula in every State,
    but a few States, the District of Columbia has never yet
    received a grant. So again, a difficult set of priorities. I
    would like to work with you to see if we can put some more
    resources on the program.
        And also, to validate the effectiveness of this proposal.
        Secretary Duncan. Yes. I appreciate that and we can look at
    that line item again, I would--I am happy to work with you in
    that, but with stimulus dollars, with Race To The Top dollars,
    it's a huge opportunity for States and districts to invest in
    creative ways. They have title I dollars, an unprecedented
    resource on the table, if folks can think about--not just line
    items, but how they can strategically use all of these
    resources to arrive at a common agenda. And that's a huge
    potential avenue for schools to improve.
        Senator Reed. I think just your sort of emphasis on school
    libraries and their role in literacy, together with those other
    resources might be a very important ingredient in this program.
        Secretary Duncan. I appreciate that.
        Senator Reed. Thank you, Mr. Chairman.

                        RACE TO THE TOP FUND COMPETITION

        Senator Harkin. Back to the RFP, the request for proposals,
    how many do you expect to award; do you have any ball park idea
    at all?
        Secretary Duncan. I really don't. Again, we are going to
    set a high bar, and so this is not--we are going to say ``No''
    to some folks and that is going to create some pressure--but
    when we say a race to the top, we literally mean that. So we
    will set a high bar, and States that hit it, that's great. And
    what we may do is we may come back with a second round, you
    know, down the road. So States that don't hit the bar now will
    come back and we will say you have another opportunity if you
    make these changes.
        We will be very, very clear to States, this is where you
    hit it and this is where you didn't. And you know, I would love
    it if at the end of the day, when we are done with this, if we
    had all 50 States doing these things, that would be phenomenal.
    I mean, our children would be in great, great shape. But this
    is going to be--we are going to be very, very clear about our
    expectations and give folks a chance to hit it now, and give
    folks a chance to come back, and where they are a little short
    or not doing something that we think is important, they will
    have the opportunity to address that, to correct it and come
    back down the road.
        We will also put all of this out for public comment. So
    before anything goes out, we are going to put out a draft and
    give folks feedback and go through that process before we
    finalize it.

                    OBLIGATION PERIOD OF RECOVERY ACT FUNDS

        Senator Harkin. Well, you are really going to have to move
    rapidly. That money is--you don't--that money expires, if I am
    not mistaken, September 30 of next year, right?
        Secretary Duncan. No, it can be used beyond.
        Senator Harkin. It has to be obligated. No?
        Secretary Duncan. We have to use it by 2010.
        Senator Harkin. That's what I mean. You have to get it out
    by 2010?
        Secretary Duncan. They have time beyond that.
        Senator Harkin. But it has to be obligated by then? Yes.
        Secretary Duncan. Yes. So we will get that out, I promise
    you.

                    RACE TO THE TOP FUND AND CHARTER SCHOOLS

        Senator Harkin. Okay. Let me ask you a question about the
    statement that said, ``States will hurt their chances to
    compete for millions of Federal stimulus dollars if they fail
    to embrace innovations, like charter schools, Secretary of
    Education Duncan said Thursday.''
        Is that it? If States have a cap on the number of charter
    schools, that they would have a harder time of winning one of
    these awards? So are charter schools a litmus test?
        Secretary Duncan. It's not a litmus test. It may be one
    factor--we are going to ask a series of questions around those
    four assurances, and so that may be a piece of that. And again,
    we haven't finalized the RFP, but it may be one of the
    questions that we ask in those topics.
        And again, let me be clear, I am not just for more
    charters, I am for more good charters. And so it's not just
    about a cap. It's much more complex than that. It's about
    having accountability, autonomy, and a high barrier to entry.
        Senator Harkin. I'm glad to hear you say that----
        Secretary Duncan [continuing]. We want to address all of
    those things.
        Senator Harkin. Yes. Because there seems to be some thought
    that you are focusing so much on charter schools, that every
    charter school is great, no matter what.
        Secretary Duncan. I try to be explicitly clear. I have
    never said that, and again, if you look at my record, I closed
    three charter schools for failure, and so I am for good schools
    of every stripe and every ilk.

                         WHAT WORKS AND INNOVATION FUND

        Senator Harkin. I am glad to clear that up and make that
    clear, that it's not necessarily a litmus test.
        There's one other thing I wanted to ask you about here, and
    that was in this What Works and Innovation Fund, I just don't
    know where this might fall. But it's been my view after all
    these years of looking at schools, and finding schools that
    work, that there are a lot of different reasons why a school
    might be successful and one year why it won't. You have to look
    at a lot of factors.

                         IMPORTANCE OF A GOOD PRINCIPAL

        But the one element that always seems to be present is
    whether or not they have a good principal.
        Secretary Duncan. Very true.
        Senator Harkin. A principal who is smart, who is dedicated,
    who knows how to organize, how to motivate teachers, it's just
    invaluable. But we haven't really had a good program for
    training principals. You are a teacher and then you become a
    principal. Well, sometimes the best teacher may not be the best
    principal. The skill set may be different.

                           SCHOOL LEADERSHIP PROGRAM

        So we have this school leadership program, and quite
    frankly, you, in your request, in your budget, you bumped it up
    a lot, $19 million. We bumped it up quite a bit from 2008 to
    2009, and then you asked for about $10 million increase, up to
    $29.2 million for 2010.
        I guess my question has to do with these RFPs that go out.
    Are you going to be looking at things like that, too?
        Secretary Duncan. Absolutely. That's exactly right--whether
    it's districts, whether it's States, whether it's universities,
    whether it's nonprofits, there are lots of folks that are
    training principals. Some are doing a great job of it and some
    aren't. We can look at the data at how those principals have
    been trained, that have done a lot in terms of driving up
    student achievement.
        Senator Harkin. Good.
        Secretary Duncan. In those places, again, districts,
    universities, nonprofits, States, whatever players might be
    doing a great job of this, there is a huge chance to do more of
    that, and I absolutely concur with you. I don't think there is
    a good school in this country without a good principal.
        I've seen quite the inverse. I have seen a school that
    struggled that had a great principal, that took 10 or 12 years
    to improve. And without the right succession plan, that good
    principal leaves, and within 6 months the place is a disaster.
    It is much, much harder to build this thing up than it is to
    tear it down.
        And just as in your business, and in any of the business,
    leadership matters tremendously. Good principals keep good
    teachers. They help good teachers improve. They work with the
    community. And so there is a huge opportunity here to invest in
    leadership, and that would cure many of the problems that ail
    us. When you see these high-performing schools in tough
    neighborhoods, every single one has a dynamic principal driving
    that change. It can't happen without it.
        Senator Harkin. I am really glad to hear you say that. So
    when I am looking at that request for the $29.2 million that
    you are requesting, but then there might be more than that in
    the----
        Secretary Duncan [continuing]. The $650 million is
    absolutely eligible for that. That's the kind of thing we want
    to invest in.

                        STATE LONGITUDINAL DATA SYSTEMS

        Senator Harkin. I am really glad to hear that. Let's see
    what else? Let me be just a bit more general.
        One of the four elements you mentioned on what you are
    looking at in these RFPs, comprehensive data systems on
    tracking students?
        Secretary Duncan. The assurances? Yes.
        Senator Harkin. There are some systems that are out there
    that do this. I don't know which are good enough, but I am sure
    you are looking at those that are existing already?
        Secretary Duncan. Yes. You bet.
        Senator Harkin. I don't know which ones are good enough,
    but I know there are some out there.
        Secretary Duncan. Again, and this is where there is huge
    variation. Some States are doing a phenomenal job of this now,
    and other States are, you know, just sort of starting off. And
    what we are saying is, we're saying that this is important. You
    need to know where your students are, you need to know how your
    teachers are doing, and you need to know how the schools of
    education are producing the teachers that are helping.
        And you have to have this fundamental basis of fact or
    otherwise we are just guessing. You can't guess at what is
    important. You need to know what is happening, and we have to
    track students throughout their educational career. You can't
    be losing students through the cracks. This is not right.

                             DATA QUALITY CAMPAIGN

        Senator Harkin. So you have already tasked someone in your
    organization to start gathering the information on this?
        Secretary Duncan. Yes, it actually goes well beyond this.
    There is an outside group, called the Data Quality Campaign,
    DQC, that has done extensive work for years in this. They have
    ranked every State. They have 10 requirements. They have a set
    of States that make all 10. They have a set of States that make
    9, 8, 7, 6, 5, and our goal would be to have every State to hit
    all 10 of those benchmarks.
        So this goes far beyond our Department. This is really a
    national movement with some clear bars and clear, objective
    criteria, and every State knows exactly where they stand. And
    we have money in the budget for data systems, and we just want
    to help every State get where they need to go.
        I think there are 6 States now that hit all 10 of those
    criteria, so we have got some work to do.
        Senator Harkin. We have a system that started in Iowa just
    a few years ago. It's not complete in the State yet, but my
    information from the school board says that they really like
    this tracking system that they have. I will have to get more
    information on it. Objectively, I don't know, how well it's
    working, but from what I hear from people, they said they are
    doing a great job of tracking students and making sure they
    know what each student--where each student is and each teacher
    knows where the student is, and where they are weak, and where
    they are strong, what happened to them last year, that type of
    thing.
        Secretary Duncan. That sounds like exactly what we are
    looking for.

                TRANSITION AFTER RECOVERY ACT FUNDS ARE EXPENDED

        Senator Harkin. Yeah. Okay. Lastly, and I don't mean to
    keep you any longer, but on the Recovery Act funding, you
    mentioned some of the guiding principles that we would be
    doing. You said that they could spend money quickly and save
    and create jobs, implement school reform, minimize the funding
    cliff that we are going to be facing. And that is a big concern
    of all of us here. But what is going to happen when we get past
    next year? Some school districts are confused how to balance
    all of this. They say, ``How do we create jobs without creating
    this funding cliff?'' How do we implement school reform if we
    just focus on creating jobs?
        I don't know that I have a real pointed question on that,
    it's just there is--and I am hearing back that there is some
    confusion from school districts out there. What am I supposed
    to do? Which is the priority: am I supposed to save some jobs,
    or am I supposed to hire some new employees, some new people?
    But then what is going to happen next year when the money runs
    out? What will happen to them?
        I keep getting input on this all the time. I just want to
    explore that with you a little bit.

               TARGETING RECOVERY RESOURCES--A TEST OF LEADERSHIP

        Secretary Duncan. It's a really, really fair question, and
    what I would really urge is, first of all, I see these things
    not as contradictory, but you need to do both--let me be clear
    on saving jobs. With the stimulus, you know, we think we are
    going to save or create well north of 300,000 jobs.
        Senator Harkin. Saving? Otherwise, it would have been more?
        Secretary Duncan. Yeah, if class size would have gone from
    25 to 40, we would have laid off librarians and social workers
    and counselors. That would have been an absolute disaster.
    Obviously, I am pushing for us to get dramatically better. If
    we would have taken a step backwards, that would have been a
    catastrophe for the country.
        So you have to do that. Simultaneously, I would push very
    hard, that if all we do is invest in the status quo, that's not
    going to get us where we need to go either. And we have to
    attack this 30 percent national dropout rate. We have to attack
    these dropout factories. We have to think differently about
    time. We have to think differently about talent. And we can do
    these things at the same time. And you are seeing real
    innovation, real creativity happen in some places, and you are
    seeing other folks that are a little bit paralyzed. And this is
    hard. This is a lot of folks under huge financial pressure.
        This is not just about principles. This is a real test of
    leadership and you are going to see some States and some
    districts and some schools do a phenomenal job of this, and
    also you are going to see some places get paralyzed, and they
    won't be able to handle the pressure.
        And I would argue, you know, Rahm Emmanuel has this
    little--the President's Chief of Staff has this great line,
    ``Never waste a good crisis.'' I really believe that. That
    sometimes it's in times of crisis, this intersection of crisis
    and opportunity, that you can sort of push this kind of
    fundamental reform. So I would argue, that if we could now,
    with existing resources, and the additional title I money that
    schools are requesting, that if we could fundamentally
    challenge some of these dropout factories and fix them, we
    would fix them forever, and we would stop this pouring out of
    kids onto the streets that have no ability to compete in
    today's economy and hold a good job, and support a family and
    own their own home.
        You know, if we train a generation of teachers to work
    better with special education students and teach those students
    to read early, we would prevent a whole other generation of
    students being labeled special ed, a label they never escape.
        So there are things that we can do now. The early childhood
    investment, if we do that well, these children are going to be
    better prepared for work and for life, you know, 20 years from
    now. So if we do the right thing now, on both fronts, we have
    this chance to fundamentally change education in our country. I
    really believe that.
        And so these things aren't in conflict. I think they can be
    absolutely complementary. But it is going to take leadership
    and vision. And we want to share best practices. So there are
    no secrets in this. We are all in this together. Because as we
    see States and districts doing innovative things, we are going
    to try to continue to highlight those best practices, so that
    other folks can steal some ideas, and we are all in this
    together. We are all in this together.

                        PROPER USE OF RECOVERY ACT FUNDS

        Senator Harkin. Well, that's very encouraging. I read
    something from the States, that they might try to siphon some
    of this money off into other areas. I hope that we are being
    diligent in trying to check that.
        Secretary Duncan. We are going to check it. And again, I am
    not looking for a fight, but we put out tens of billions of
    dollars, but we withheld tens of billions of dollars. We did
    that for a reason. That's exactly the reason. So that's, again,
    that's the stick side. The carrot side is unprecedented
    discretionary resources. And if States are gaming things, they
    are basically going to walk away and eliminate themselves from
    the hundreds of millions of dollars in additional resources
    coming to their State. So we are trying to push very hard on
    both sides, carrots and sticks, to get States to do the right
    thing.
        I know the pressure they are under. I know the difficulties
    and I don't imagine--and it varies. Some States are in
    disastrous situations, but everyone is under stress. But again,
    this is a test of leadership. When you are under stress, what
    do you do?
        This is a real test of leadership right now.

                      RECOVERY ACT INVESTMENT IN EDUCATION

        Senator Harkin. Well, it is a real test and I think that
    the President was very bold in the Recovery Act, and I think
    that he met that by putting that money in there for education.
    I think the total was about $100 billion.
        Secretary Duncan. North of that. It is a phenomenal
    investment and I appreciate your tremendous leadership in this.
        Senator Harkin. Now we just want to make sure that we use
    it well and wisely. I can't tell you how much I like everything
    I hear coming from you, and from the President on this, and
    that we are going to make some real changes and just get us
    really in a new direction on education. So whatever--we will
    look at these budgets and these numbers and we will obviously
    will be consulting with you and your people on this as we go
    through our appropriations cycle here.

                NO CHILD LEFT BEHIND AND NARROWING OF CURRICULUM

        The last thing I just wanted to mention. This is not very
    appropriate probably for this year, it would be probably more
    appropriate in my other hat on the authorizing committee, but
    what the heck, you are here and I am here.
        I can't tell you how many times I met with your
    predecessor, Margaret Spellings, on the issue of No Child Left
    Behind. And that what we had seen is because of these AYPs, and
    the focus on schools to do more on math and science, that what
    we found is that schools under this pressure were trying to
    pour money into that, and the first people to go were their art
    teachers and music teachers and physical education teachers.

               IMPORTANCE OF ARTS AND PHYSICAL EDUCATION COURSES

        So there are two areas: one, the physical health of our
    kids in school. When you build an elementary school without a
    playground, I don't know what statement you are making about
    the health of our kids. I had this quote from this one
    principal that said that, ``We are in the business of teaching
    kids, not letting them play around on monkey bars'', when asked
    about the fact that they had built a school without a
    playground. And so the health of our kids is important in those
    early years.
        But also Wynton Marsalis just gave a great 1 hour discourse
    on culture at the Kennedy Center, about a month or so ago. It
    was one of the most fantastic discourses on American culture,
    and the history of culture as it is interwoven with the arts
    and music. And it just seems that we do ourselves a disservice
    if we don't have, again, a school education for those kids
    where they learn about art and music, and what music means. And
    not every kid is talented enough to be in math or science, but
    they may have other talents. They may have talents in artistic
    fields, and we have to engender that. And I just think we are
    falling way behind on that. We are just getting it short
    shrift, as though it's not important. I would submit it is
    vitally important, and so again, with all this pressure from No
    Child Left Behind, I hope we think about those other two
    things. And don't leave them behind in terms of their health,
    and don't leave them behind in terms of their culture, and
    their appreciation for culture and the arts, music, and that
    type of thing.
        I just wanted to state that to you.
        Secretary Duncan. I couldn't agree with you more. I worry a
    lot about the narrowing of the curriculum. I think our students
    desperately need arts and music and dance and drama. They need
    health. They need PE. I think we have to give students multiple
    opportunities to develop their unique skills and passions and
    talents and give them a reason to be excited about coming to
    school every single day.
        For me, it was sports. For another kid, it might be debate
    or chess or dance, or drama. We have to provide those
    opportunities. Our students have to be healthy. They have to be
    physically active.
        You and I went to a phenomenal school that I will never
    forget in your State that has an absolutely state-of-the-art PE
    program. But, guess what? I am convinced that students are
    going to do better academically because of what is going on
    there and the lessons that are being learned.
        So, again, it's so funny when people always talk about
    these things being contradictory. Monkey bars, if they spent
    some time on the monkey bars, I think they will learn more. I
    was one of those young kids that couldn't sit still all day.
    This is a long time, frankly, for me to sit still here. It's
    still a challenge; I need some monkey bars. But kids need to
    get up, to get some fresh air and run around a little bit. I
    worry a lot about our young kids that don't have those kinds of
    opportunities.

               IMPORTANCE OF DEVELOPING ALL SKILL SETS IN SCHOOL

        So these things to me aren't contradictory. They absolutely
    need to--do you want to improve math scores? Do some music.
    There is actually a lot of data about that. And so I go back to
    the narrowing of the curriculum, that's a problem. The school
    day being too short, we can't pack all this stuff in. We have
    got to get some more time. So this could be before school,
    after school----
        Senator Harkin. A longer school year.
        Secretary Duncan [continuing]. At lunch time, a longer
    school year, summer enrichment, so if a kid is great at the
    piano or violin or dancing, drama, it's not just more of the
    same, but for somebody to have the chance to build upon those
    skills.
        And so I think we have a real chance to be creative and to
    stop those sort of false dichotomies and false battles, and say
    that every kid needs these kinds of opportunities and let them
    figure out what the right path is for them. So, this is one
    that we want to spend a lot of time and thought on and try and
    get it right.
        Senator Harkin. Well, how can we be helpful both on the
    authorizing end, but also on this end, the Appropriations
    Committee, if there are things that we need to pilot or we need
    to look at in terms of boosting some funds some place, to
    enhance that, I would like to know your thoughts on that. We
    may have some of our own, but we would like to hear your
    thoughts.
        Secretary Duncan. I look forward to that.

                         ADDITIONAL COMMITTEE QUESTIONS

        Senator Harkin. Mr. Secretary, thank you very much. You
    have been very generous with your time and input and I'm sure
    that we will be dealing with your people and others as we move
    ahead on this appropriations process.
        Secretary Duncan. Thank you so much for your leadership. I
    really appreciate it.
        [The following questions were not asked at the hearing, but
    were submitted to the Department for response subsequent to the
    hearing:]
                   Questions Submitted by Senator Tom Harkin
     data on lea reduction of expenditures for special education under the
               individuals with disabilities education act (idea)
        Question. The Recovery Act provided $11.3 billion under IDEA Part B
    (section 611) Special Education State grants program. These funds were
    intended to save jobs and improve student achievement through
    investments in evidence-based practices with the potential for long-
    term benefits. A provision in the IDEA allows States or school
    districts meeting requirements under IDEA to use funding increases
    received over the prior year to reduce levels of special education
    expenditures by up to 50 percent of the prior-year amount. What
    information has the Department collected on the number of districts and
    States using this provision up through the current academic year?
        Answer. IDEA, section 613(a)(2)(C), permits (local education
    agencies (LEAs) that meet certain conditions to reduce their required
    level of local, or State and local, expenditures on special education
    by up to 50 percent of any increase in the LEA's allocation under IDEA,
    section 611. The Department does not have any data on the numbers of
    districts that have taken advantage of the flexibility available to
    LEAs under this provision in prior years. We do not currently have a
    data collection in place to collect this information; moreover, we have
    not learned of any districts that have taken advantage of this
    flexibility.
        While we suspect that many more LEAs will be interested in taking
    advantage of this flexibility during the current fiscal year, it is
    worth noting that only certain LEAs will be eligible to do so. For
    example, pursuant to section 616(f), State educational agencies (SEAs)
    must prohibit any LEA that does not currently meet the requirements of
    the Act from taking advantage of this local maintenance of effort
    flexibility.
           data collection on lea reduction of maintenance of effort
        Question. Will the Department collect for the current academic year
    and future academic years the number of districts and States reducing
    maintenance of effort under current law; the amount of IDEA funds being
    used for purposes authorized under the Elementary and Secondary
    Education Act (ESEA); and the major categories of ESEA expenditures
    made using these IDEA resources?
        Answer. The Department is currently developing a data collection
    instrument that will be used to obtain information on the extent to
    which LEAs reduce their special education expenditures under IDEA,
    section 613(a)(2)(C), or use funds for coordinated early intervening
    services under section 613(f). While this data collection package has
    not yet been formally approved, the agency is working to implement this
    collection in time to obtain data for the 2009 fiscal year.
       data on states ineligible to use maintenance of effort reduction
                                   authority
        Question. What information does the Department have available on
    the number of States and districts ineligible to utilize the
    maintenance of effort (MOE) reduction authority for reasons of:
    mandatory early intervening services, State not meeting requirements
    under IDEA or districts not meeting requirements under IDEA?
        Answer. The Department does not currently have complete data on the
    number of LEAs that may be ineligible to utilize the MOE flexibility
    under section 613(a)(2)(C), either because those LEAs do not meet
    requirements or because they are required to spend the full mandatory
    15 percent on coordinated early intervening services due a finding of
    significant disproportionality based on race and ethnicity. However, we
    do have information for particular States.

    ----------------------------------------------------------------------------------------------------------------
                                                                                  Number of LEAs    Number of LEAs
                                                                                   not in meets     identified with
                                State                             Number of LEAs   requirements       significant
                                                                                    status (in    disproportionality
                                                                                   2007 or 2008)   (in 2007 or 2008)
    ----------------------------------------------------------------------------------------------------------------
    Arizona.....................................................             590             296           ( \1\ )
    Arkansas....................................................             244         ( \1\ )                23
    California..................................................             980              85           ( \1\ )
    Connecticut.................................................             180              66           ( \1\ )
    Florida.....................................................              67              16           ( \1\ )
    Georgia.....................................................             180         ( \1\ )                72
    Hawaii......................................................               1  ..............           ( \1\ )
    Idaho.......................................................             129         ( \1\ )                 6
    Indiana.....................................................             338         ( \1\ )                 7
    Kentucky....................................................             176         ( \1\ )                 4
    Louisiana...................................................              96              56           ( \1\ )
    Maine.......................................................             154              51           ( \1\ )
    Massachusetts...............................................             391         ( \1\ )  ..................
    New York....................................................             683              51                 5
    Ohio........................................................             941             542           ( \1\ )
    Rhode Island................................................              52              14                29
    South Carolina..............................................              86         ( \1\ )                 4
    Tennessee...................................................             136             131                21
    Texas.......................................................           1,230             523           ( \1\ )
    Virgin Islands..............................................               2               2           ( \1\ )
    Wisconsin...................................................             471             137           ( \1\ )
    ----------------------------------------------------------------------------------------------------------------
    \1\ Not known.

                  long-term impact of recovery act idea funds
        Question. Lastly, what is the Department's view of the long-term
    impact of Recovery Act IDEA dollars being used to reduce special
    education expenditures?
        Answer. It is not yet clear what the long-term impact of Recovery
    Act IDEA dollars will be, but the Department's goal is to ensure that
    LEAs use these emergency one-time funds to avoid teacher layoffs and
    support essential services, in addition to making investments in
    improving student outcomes and advancing reforms that will have a
    positive long-term impact.
        technical assistance for special education state data collection
        Question. The budget request assumes that $15 million of part B
    Special Education State grants will be used for special education
    technical assistance related to data collection for State Performance
    Plans and Annual Performance Reports, as well as ensuring that LEAs are
    meeting the requirements of IDEA. How will requested funds be used to
    support these activities?
        Answer. Under technical assistance for the State Data Collection
    program, established under section 616(i)(2) of IDEA, the Department
    makes competitive awards to provide technical assistance to improve the
    capacity of States to meet the section 616 data collection
    requirements. During fiscal year 2010, the Department expects to make
    approximately $13 million in new awards to States, but the focus of
    this upcoming competition has not yet been determined.
    Technical Assistance Center on IDEA Accountability Data
        The request would also support one $2 million continuation award to
    support a Technical Assistance Center on IDEA Accountability Data
    (called the Data Accountability Center). This project provides
    assistance and information to States to help them improve data
    collection infrastructures and to implement the requirements under
    section 616. This on-going project focuses on the following three
    areas: assessment of State needs; strategic planning and evaluation;
    and provision of technical assistance to States.
            additional support for states related to data collection
        Question. What other Department of Education resources are being
    used currently and are requested in the fiscal year 2010 budget to
    assist States in carrying out their responsibilities in these areas?
        Answer. The Department has not yet decided the focus areas for
    upcoming competitions during fiscal year 2010. The primary source of
    additional support to States on activities related to data collection
    comes from centers funded through the IDEA Technical Assistance and
    Dissemination program, including the Regional Resource Centers (for
    which $7.8 million was awarded in fiscal year 2009 to support
    approximately 4 new awards) and the Post-School Outcomes Center (which
    receives approximately $800,000 per year, over 5 years, beginning in
    fiscal year 2008).
       special education grants to states program improvement strategies
        Question. The Congressional Budget Justification indicates that one
    of the Program Improvement Efforts under Special Education part B
    Grants to States is ``identifying strategies in key topic areas that
    have the potential for improving results for children with
    disabilities.'' Specifically, what strategies has the Department
    identified and on what basis has it targeted these particular
    strategies?
        Answer. The Department has identified strategies in a variety of
    areas, including: supporting on-going, formative, school-wide
    strategies such as multi-tiered interventions and Positive Behavioral
    Intervention Strategies (PBIS); enhancing general education and special
    education teacher effectiveness by supporting professional development
    and more effective pre-service training for teachers and school
    leaders; requiring all special educators to be highly qualified;
    improving the curricula of pre-service teacher training programs;
    supporting formal induction and mentoring programs, and incorporating
    assistive technology into classroom teaching practices; establishing
    coordinated data systems and using data to improve student outcomes;
    incorporating universal design for learning principles as widely as
    possible, and; encouraging States to adopt rigorous standards,
    curricula, and assessments and ensuring that students with disabilities
    have an opportunity to participate alongside their general education
    peers to the greatest extent possible.
        The Department targets these areas by making them the topical focus
    of competitions under special education discretionary grant programs,
    and by encouraging States to use funds available through the grants to
    states, preschool grants, and grants for infants and families formula
    programs to support authorized activities related to these strategies.
               funding sources for program improvement strategies
        Question. How much funding (and what funding sources) is dedicated
    to implementing these strategies in the current fiscal year and how
    much is included in the fiscal year 2010 budget request to continue
    and/or expand on these efforts?
        Answer. The Department has not yet decided the focus areas for
    upcoming competitions during fiscal year 2010. However, special
    education discretionary grants programs are the primary source of
    funding used to support strategies in key topic areas that have the
    potential for improving results for children with disabilities.
    Special Education Pre-service Training, Professional Development, and
            In-service Training
        For example, the Personnel Preparation Program is the key source of
    funding used to support key strategies related to pre-service training,
    professional development, and in-service training for special educators
    and school leaders. In fiscal year 2009, in additional to several new
    competitions, the Department is supporting continuation awards that
    target a wide range of strategies that are likely to improve results
    for children with disabilities.
        For example, Personnel Preparation Program investments in fiscal
    year 2009 include:
      --A new award to a consortium of universities that will produce at
            least 30 new doctoral candidates in the area of low-incidence
            sensory disabilities, including visual and hearing impairments
            ($5 million over 5 years beginning in fiscal year 2009).
      --Up to 15 new Paraprofessional Pre-Service Training Improvement
            grants. These grants will focus on improving pre-service
            training programs for paraprofessionals who serve children ages
            birth through 5, and children in grades kindergarten through
            grade 12, by enhancing or redesigning curricula to adequately
            train these paraprofessionals to address the needs of infants
            and toddlers with disabilities and their families.
      --A single continuation award to support the Center to Improve the
            Recruitment and Retention of Special Educators ($2.5 million
            over 5 years).
      --Preparation of Leadership Personnel Grants.--The Department will
            make approximately $5 million in new awards (to 23 grantees)
            and $12.3 million in continuations (to 68 grantees) in fiscal
            year 2009 to train personnel at the pre-service doctoral or
            postdoctoral level in early intervention, special education, or
            related services, and at the advanced graduate level (masters
            and specialists).
      --Pre-service Improvement Grants.--The Department will make
            approximately $1.5 million in new awards (to 12 grantees) and
            $4.1 million (to support 48 continuation awards) in fiscal year
            2009 to institutions of higher education to ensure that pre-
            service training programs and curricula are aligned with the
            highly qualified teacher requirements.
        special education technical assistance and dissemination program
        Question. The Congressional Budget Justification under the
    Technical Assistance and Dissemination Program narrative indicates that
    the Department will be collecting performance and other information to
    adjust issue coverage and reallocate resources for this program. Please
    provide the information being used in this process and identify
    specifically how funding would be reallocated under the budget request.
        Answer. On an on-going basis the Office of Special Education
    Programs (OSEP) works to ensure that resources available under this
    program are invested in critical areas of need. In identifying new
    topics for funding priorities and allocating resources OSEP considers:
    Institute for Education Sciences (IES) research findings; information
    on the needs of SEAs and LEAs and other important customers and
    constituencies; results from formal program evaluations; and, other
    relevant materials. OSEP has also established an internal Technical
    Assistance and Dissemination (TA & D) workgroup. This group maps all
    current TA & D investments, identifies discrepancies and emerging
    trends, proposes modifications to the scope of work in current
    investments, recommends projects that should be phased-out, and
    recommends new priorities.
        The Department has not yet decided the focus areas for upcoming
    fiscal year 2010 competitions.
              recruiting and retaining special education teachers
        Question. The Teacher Quality Under No Child Left Behind.--Final
    report documents the particular challenge that high-poverty schools
    face in recruiting and retaining special education teachers. What
    specific activities (and funding sources) will be undertaken to address
    this issue in fiscal year 2009 and under the fiscal year 2010 budget
    request?
        Answer. Severe shortages in the supply of special education
    teachers have been documented for at least 15 years, and the problem is
    particularly acute in high-poverty districts. The Department has
    adopted a number of strategies to alleviate on-going shortages of
    special education teachers, including:
      --Supporting initiatives that are designed to improve the overall
            quality of special education training programs, to ensure that
            all special educators are highly qualified, and consequently to
            reduce the high turnover-rate of new and veteran special
            educators teachers. For example, since fiscal year 2007 the
            Department has made approximately 56 Special Education Pre-
            Service Training Improvement grants to institutions of higher
            education for the purpose of restructuring or redesigning
            preparation programs for special educators who teach grades K
            through 12 to ensure that training program curricula are
            aligned with evidence-based practices and that all graduates
            meet the highly qualified teacher requirements upon program
            completion. During fiscal year 2009, the Department is using
            $1.4 million in Personnel Preparation funds to make
            approximately 12 new awards in this activity area.
      --Focusing limited Federal resources for scholarship support in areas
            where such investments are likely to have the greatest impact
            on supply (e.g., supporting scholarships in programs that
            prepare teachers of children with low-incidence disabilities
            and leadership personnel). During fiscal year 2009, the
            Department is using $4.5 million to support approximately 23
            new awards in this area.
      --Supporting novel strategies to attract and retain special education
            teachers, such as alternative teacher certification programs,
            high-quality professional development, partnerships between
            institutions of higher education and LEAs (particularly with
            high-poverty LEAs/schools), and mentoring programs for recent
            graduates from training programs. For example, the Department
            supports the National Center to Improve the Recruitment and
            Retention of Qualified Personnel for Children with Disabilities
            to help States develop and implement strategies to recruit and
            retain sufficient numbers of highly or fully qualified
            personnel.
    Fiscal Year 2009 State Personnel Development Grant Focus on Promising
            Strategies
        Section 14005(d)(2) of the Recovery Act requires each State, as a
    condition of receiving State Fiscal Stabilization Funds (SFSF), to
    commit to taking ``actions to improve teacher effectiveness and comply
    with section 1111(b)(8)(C) of the ESEA . . . in order to address
    inequities in the distribution of highly qualified teachers between
    high- and low-poverty schools, and to ensure that low-income and
    minority children are not taught at higher rates than other children by
    inexperienced, unqualified, or out-of-field teachers.'' Consistent with
    the requirements of section 14005(d)(2), in fiscal year 2009 the
    Department is encouraging competitive applicants under the State
    Personnel Development Program to address these challenges by awarding
    additional points to applicants who propose promising strategies.
        The Department has not yet decided on priorities for upcoming
    fiscal year 2010 competitions.
                  educational materials in accessible formats
        Question. Under the Technology and Media Services Program, funds
    are included for a competition for State System Improvement Grants
    which are intended to support the development or improvement of State
    systems for providing to students with disabilities educational
    materials in accessible formats. The Congressional Budget Justification
    describes initial awards made under this program as ``very
    successful.'' What information enabled the Department to come to this
    conclusion about these awards?
        Answer. In September 2007, the Department made awards under the
    ``Educational Media Activities to Improve State Systems for Providing
    Educational Materials in Accessible Formats'' priority to two
    consortia:
      --The Accessible Instructional Materials (AIM) Consortium, which
            represents 15 States serving more than 1.3 million students
            under IDEA, of whom more than one-half million are estimated to
            have print disabilities; and
      --The Pacific Consortium for Instructional Materials Accessibility
            Project (CIMAP). The Pacific CIMAP facilitates the
            collaborative efforts of the six Pacific Basin entities to
            build local and regional capacity for implementation of the
            National Instructional Materials Accessibility Standard (NIMAS)
            and National Instructional Materials Access Center (NIMAC)
            requirements, as well as all other accessibility requirements.
    Educational Media Activities To Improve State Systems for Providing
            Educational Materials in Accessible Formats
        The goals of the educational media activities to improve State
    systems in accessible formats are to:
      --Facilitate the development of State systems for increasing the
            awareness and timely provision of accessible instructional
            materials via NIMAS/NIMAC for qualifying students and other
            means for nonqualifying students;
      --Ensure that State systems for the identification, acquisition, and
            use of accessible instructional materials employ high-quality
            procedures and practices; and
      --Produce related products and services that are scalable and can be
            made available to all States, Outlying Areas (OAs), and Freely
            Associated States (FAS), thus contributing to improving
            outcomes for all students with disabilities.
        Making available appropriate accessible materials in a timely
    manner is key to improving outcomes for children and youth who are
    blind or have print disabilities. Every State and Pacific entity has
    indicated that it has made significant progress in implementing high-
    quality sustainable systems that ensure the provision of textbooks and
    related instructional materials in specialized formats in a timely
    manner to students with disabilities. The information that follows
    indicates that the participants in these projects are significantly
    ahead of where they were 18 months ago in leveraging local, State, and
    national resources so that students with print disabilities receive
    appropriate, accessible, and accurate core curriculum materials in a
    timely manner. State leaders involved in the consortia unanimously
    attribute much of their ability to move forward to the work of the
    consortia.
        Educational materials obtained through source files provided by the
    NIMAC only may be provided to students who meet the eligibility
    requirements of the Act to Provide Books for the Adult Blind of March
    3, 1931. However, the definition of eligibility promulgated to meet the
    requirements of this Act does not cover many students who are eligible
    under IDEA or students eligible under section 504 of the Rehabilitation
    Act of 1973. The consortia have addressed the needs of both students
    who are eligible for materials created from NIMAS sources files and
    those who are not eligible for instructional materials produced from
    this source, but who have been determined to require accessible
    educational materials.
    AIM Consortium
        Regarding the AIM Consortium, data indicate that there are 1.3
    million students with disabilities served under IDEA in the 15 States
    participating in the project. It is estimated that 500,000 of those
    students require accessible instructional materials of some sort. This
    number does not include students with learning disabilities who do not
    meet the eligibility requirements for materials produced from NIMAC
    source files or children with disabilities who receive services under
    section 504 of the Rehabilitation Act.
        Throughout the grant period, the AIM Consortium and its independent
    evaluator have collected baseline data, periodic formative data, and
    summative data to determine progress and the potential impact of the
    work of the Consortium. To ensure that high- quality procedures and
    practices are used by the AIM Consortium, the Consortium's Steering
    Committee, made up of leaders from each of the 15 States, developed 7
    Quality Indicators for the Provision of Accessible Instructional
    Materials to guide the development of high-quality, sustainable
    systems. Those quality indicators have been the basis of information-
    gathering on the status of State delivery systems, public awareness
    efforts, and targeted technical assistance. Data gathered in the fall
    of 2008 indicate that the current status of State systems on each of
    the indicators is markedly improved from the baseline obtained at the
    beginning of the grant period.
    Progress of AIM Consortium States in Developing Systems To Provide
            Accessible Instructional Materials
        The following table provides data on the progress the AIM
    Consortium States have made toward the development of individualized
    systems that align to the critical elements of high- quality systems
    for the provision of accessible instructional materials. The rating
    scale used to gather these data was: 1=Emerging; 2=Planning stages;
    3=Under development; 4=Partly implemented; and 5=Fully implemented. The
    first number in the table is the mean rating that was reported by the
    AIM State Leaders at the beginning of the grant period. The second
    number represents the mean rating for the most recent data collection
    in February 2009, and the third number indicates the change between the
    baseline and the most recent data collection.

         MEAN PROGRESS RATINGS IN DEVELOPING DELIVERY SYSTEMS FOR DELIVERY OF ACCESSIBLE INSTRUCTIONAL MATERIALS
    ----------------------------------------------------------------------------------------------------------------
                                                                    Mean rating--     Mean rating--
                          Quality indicator                            October          February          Change
    ----------------------------------------------------------------------------------------------------------------
    The education agency supports the provision of appropriate,                2.5              4.1             +1.6
     high-quality instructional materials in specialized formats
     to all students with print disabilities who require them....
    The education agency supports the provision of appropriate                 2.5              4.0             +1.5
     specialized formats in a timely manner......................
    The education agency develops and implements written                       1.9              3.7             +1.8
     guidelines to define the responsibilities and actions needed
     for effective and efficient provision of specialized formats
    The education agency supports learning opportunities and                   2.1              4.2             +2.1
     technical assistance (e.g., professional development,
     training, and support) to facilitate the identification of
     students with print disabilities, as well as the selection,
     acquisition, and use of appropriate specialized formats.....
    The education agency develops and implements a systematic                  1.3              3.1             +1.8
     process to monitor and evaluate the equitable, timely
     provision of appropriate, high-quality materials in
     specialized formats.........................................
    The education agency uses data to guide changes that support               1.3              2.7             +1.4
     continuous improvement in the selection, acquisition, and
     use of accessible instructional materials...................
    The education agency allocates resources sufficient to ensure              1.9              3.8             +0.9
     the delivery and sustainability of quality services to
     students with print disabilities............................
    ----------------------------------------------------------------------------------------------------------------

    Educational Materials in Accessible Formats--Other Accomplishments
        State leaders have also provided information on the following
    accomplishments:
      --Formulation of definitions of ``timely manner.'' (Each State has to
            develop its own definition.)
      --Coordination with the NIMAC and designation of authorized users. (A
            recent NIMAC report indicates that AIM States were responsible
            for 34 percent of the files that have been drawn down or
            assigned to date.)
      --Establishment of relationships with other federally funded NIMAS-
            related projects such as Bookshare for Education, Recording for
            the Blind and Dyslexic (RFB&D), and the American Printing House
            for the Blind (APH). (The Pacific entities did not have
            relationships with these programs prior to the grant.)
      --Collaboration with State assistive technology service providers.
    Web Links to Overview of Three State Systems for Educational Materials
            in Accessible Formats
        Although every AIM State has developed a system specifically
    focused on the needs of that State and its students, three systems are
    included here as examples. URLs shown below provide access to overviews
    of those systems: Iowa at http://trueaim.iowa.gov/; Maine at http://
    aim.mainecite.org/; and Louisiana at http://www.atanswers.com/aim/
    downloads.html.
    AIM Consortium Products
        Based on input from the AIM Steering Committee, the AIM Consortium
    is also developing a suite of best practices products and Services that
    addresses critical areas of decisionmaking, which will be made readily
    available to all States, FASs, and OAs by the fall of 2009. Each of the
    products in the suite is designed to support high-quality collaborative
    decisionmaking by school personnel, families, and students about the
    selection, acquisition, and use of specialized formats of textbooks and
    related core materials. The primary means of distribution will be via
    the fully accessible AIM website.
        AIM Consortium products include:
      --The AIM DVD includes a variety of topics important to the
            selection, acquisition, and use of accessible instructional
            materials. The DVDs are expected to be accompanied by resource
            materials, possible sample lesson plans, and other training
            supports that would make the videos useful across multiple
            environments.
      --The AIM Decision Making Guidelines provides a suite of tools
            (procedures/supports/materials) that increase awareness,
            knowledge, and skills related to AIM for IEP team members (the
            primary target group), policymakers, curriculum committee
            members, materials procurement personnel, publishers, and
            members of organizations with interest in and/or
            responsibilities related to the education of students with
            disabilities.
      --The AIM Demonstration Software project provides training and
            support to educators and parents involved with the selection,
            conversion, and use of student-ready accessible instructional
            materials. The primary product in this project is a dual-
            platform laptop computer for each of the participating AIM
            Consortium States, on which will be loaded an extensive suite
            of assistive technology applications that support the use of
            AIM.
      --The User's Guide to Federally-Funded Accessible Media Producers
            will provide an overview of federally funded Accessible Media
            Producers, the resources available from each, who can use them,
            and detailed step-by-step instructions on how to access the
            resources.
      --The online graduate level course entitled, ``AIM 102'' is designed
            to provide practical, hands on experience in the acquisition
            and creation of student-ready specialized format versions of
            print instructional materials. This course is the second in the
            AIM online course series (prerequisite: AIM 101: Accessible
            Instructional Materials). The course will cover the creation/
            acquisition of digital materials (DAISY book, html, etc.), scan
            and read systems, supported reading software, large print,
            Braille, and tactile graphics.
      --A toolkit for implementation entitled ``Using AIM in the Classroom:
            A Model for Implementation and Efficacy'' consists of a suite
            of materials that can be used by SEAs and LEAs interested in
            supporting the use of AIM with text-to-speech technology and to
            measure efficacy in achieving successful outcomes. Model
            materials for classroom implementation including a text-to-
            speech training module, overview DVD, pre- and postdata
            collection elements/forms, and a project planning
            implementation checklist.
        Provision of professional development and training to key
    stakeholders is a major part of the work of the AIM Consortium. Data on
    professional development and training reported by AIM State Leaders
    indicate that more than 6,250 participants received training in more
    than 215 sessions conducted across the 15 AIM States during the grant
    period to date. Responses to a recent informal query sent to the Aim
    State Contacts Listserv indicate that before the start of the AIM
    Consortium, training related to the provision of accessible
    instructional materials either did not occur or was limited to
    awareness of NIMAS and NIMAC, and the creation of accessible formats
    via assistive technology.
    Pacific Consortium for Instructional Materials Accessibility Project
            (CIMAP) Project Accomplishments
        Some specific accomplishments of the CIMAP include connecting
    consortium members with available resources, such as the American
    Printing House for the Blind and Bookshare for Education; helping them,
    after the determination was made that the areas are not covered by the
    exemptions to the U.S. copyright law, to find other sources they can
    use to obtain accessible versions of educational materials; and
    providing appropriate forms and materials for the entities to use in
    making direct requests to publishers for permission to make accessible
    copies of educational materials. In addition, the members made
    improvements in how they identify students with print disabilities,
    established a database for children with print disabilities, and
    provided training on how to identify and select materials and use them
    in instruction.
    Accessible Educational Materials Competition
        Question. How will the fiscal year 2010 competition be structured
    to build on what was learned through the initial competition?
        Answer. We have learned a lot from these projects. They have acted
    as a laboratory for identifying barriers to the provision of accessible
    materials in a timely manner and creative solutions to these problems.
    In addition to working directly with the 15 States and pacific
    entities, the grantees have worked closely with the NIMAC, the NIMAS
    Technical Assistance Center, Recording for the Blind and Dyslexic,
    Bookshare for Education, the American Printing House for the Blind,
    publishers, and publishing association representatives to ensure that
    issues identified by the States and findings, creative solutions, and
    model practices developed by the projects are disseminated to all of
    the States.
    Challenges to Timely Provision of Accessible Instructional Materials
        Despite the progress made by the two consortia, there are a number
    of major areas where continued support of the initiative to provide
    accessible instructional materials to students who require them is
    critically needed. Some of the challenges to timely provision of
    accessible instructional materials that remain include, but are not
    limited to:
      --Ambiguity related to the term ``print disability'';
      --Differing interpretations of who can determine that a student meets
            eligibility criteria for accessible instructional materials
            produced from source files obtained through the NIMAC;
      --The provision of materials to students who are ineligible for
            accessible instructional materials produced from source files
            obtained through the NIMAC;
      --Systematic quality control across the distribution process: file
            creation, storage, retrieval and transformation; and
      --Efficiency and the elimination of redundant effort.
        In addition, while much progress has been made, many States are
    still struggling. Only 15 States and the 6 Pacific Basin entities have
    had opportunities for direct support and collaboration through these
    projects. However, a majority of the States wanted to participate in
    this program. We believe that many other States could benefit from the
    opportunity to participate in the program.
    Fiscal Year 2010 Proposal for new Consortium
        The current projects end in September 2009. In fiscal year 2010 we
    would propose to support a new consortium of States that have not
    participated in the AIM Consortium or Pacific CIMAP, but that would
    benefit from support and collaboration as they implement systems to
    address the needs of students with disabilities, regardless of where
    they are located or their eligibility for materials produced from NIMAC
    source files. These States also would be expected to work closely with
    the NIMAS technical assistance center and other entities involved with
    the production of accessible materials to ensure that effective systems
    that address the needs of all students are implemented in all of the
    States.
                      video description grant competition
        Question. The Congressional Budget Justification indicates that
    $2.5 million is included for new projects and $1.1 million for
    continuation projects for support of video description and closed-
    captioning of educational programming that would otherwise not be
    required to be described or captioned. How many projects and how much
    funding would be dedicated to a video description grant competition in
    2010?
        Answer. The entire $2.5 million would be dedicated to the video
    description grant competition in fiscal year 2010. We estimate that
    approximately five new projects would be funded through this
    competition.
                    video description performance assessment
        Question. What has been the Department's evaluation/assessment of
    projects funded previously?
        Answer. The Department has not conducted any formal evaluations or
    assessments of the video description projects. However, as part of the
    Department's annual Government Performance and Results Act process, we
    annually select a sample of Technology and Media Services projects to
    evaluate. For example, in fiscal year 2008, a panel of six special
    education experts reviewed a sample of projects that produced products
    in the previous fiscal year. This included four projects that produced
    described video or a combination of described video and captioning. The
    products were assessed, using a nine-point scale, along three
    dimensions: quality, relevance, and usefulness. Successful products are
    defined as those scoring 6.0 or above. These products scored an average
    of 6.5 on the quality dimension, 8.06 for relevance, and 7.81 for
    usefulness. The Department also attempts to assess the efficiency of
    the program by looking at the number of hours of captioning and video
    description obtained from its products in relation to its expenditures.
    For fiscal year 2008, the average cost for the captioning and
    descriptive video products that were reviewed was $89.41 per hour.
          rehabilitation services and disability research--vocational
                      rehabilitation state grants program
        Question. In May 2009, the percent of people with disabilities in
    the labor force was 22.9 compared with 71.1 for persons with no
    disability. The unemployment rate for those with disabilities was 13.7
    percent, compared with 8.9 percent for persons with no disability. The
    fiscal year 2010 budget includes more than $3.5 billion under this
    account to support programs of vocational rehabilitation (VR) and
    independent living for individuals with disabilities.
        What actions is the Department taking currently (or planning for
    fiscal year 2010) to assist State Vocational Rehabilitation agencies in
    increasing the number of individuals achieving and sustaining
    employment and how does the current budget and 2010 budget request
    support these actions; and lastly, what resources are available in the
    current year and included in the fiscal year 2010 budget request to
    support improved outcomes at State VR agencies?
        Answer. The Department has undertaken three major initiatives in
    its effort to improve the performance of the VR State Grants program.
    These include implementing a new monitoring process that focuses on the
    performance of State VR agencies, enhancing the Rehabilitation Services
    Administration's (RSA) capacity to provide technical assistance, and
    developing a strategic performance plan for the VR program.
        As you are aware, in fiscal year 2005, the Department redesigned
    its monitoring and technical assist activities to focus on performance
    and assist State VR agencies in increasing the number of individuals
    achieving and sustaining employment. Monitoring was centralized to
    ensure more uniform procedures, and a new organizational structure
    integrated RSA's data collection with monitoring activities so that the
    process of review and improvement is continuous and reduces the time
    period between assessing performance and conducting reviews. As
    performance and other issues are identified, RSA provides technical
    assistance directly to State VR agencies through the RSA monitoring
    team.
    Monitoring and Technical Assistance Puts Performance Improvement at
            Forefront of RSA Activities
        Investments in developing information from RSA databases for
    monitoring and technical assistance purposes has put performance
    improvement at the forefront of RSA activities. Current monitoring
    efforts are facilitated by several tools that provide information
    essential for the focus on performance. An enhanced RSA Management
    Information System (MIS) includes various data sets developed for
    performance monitoring purposes that allow RSA and State VR agency
    staff to perform ad hoc queries on RSA databases and download data in
    MS Excel format from the RSA-2 Cost Report and the RSA-113 Quarterly
    Caseload Report data bases. Various sets of data tables are developed
    annually for use by RSA monitoring teams and State VR agencies for
    performance monitoring purposes. These data tables are a central
    beginning point for each State VR monitoring activity, and are used by
    RSA staff and State VR agency staff to discuss and identify program
    areas in need of improvement or in need of further discussion and
    investigation during on-site reviews. Performance information is
    presented and discussed in each on-site monitoring review. These data
    are also used to prepare annual review reports that include information
    about each State VR agency's program outcomes, use of resources, and
    performance on standards and indicators.
    Technical Assistance and Continuing Education (TACE) Centers
        A range of activities to assess and improve the performance of the
    VR program are also being conducted with support from other resources
    within RSA and the National Institute for Disability and Rehabilitation
    Research (NIDRR). The Department also recently established 10 new
    regional TACE Centers under the training program to provide technical
    assistance and continuing education to State VR agencies and other
    entities involved in the provision of vocational rehabilitation and
    independent living services. The TACE Centers assess the performance
    and compliance needs of agencies in their regions, including needs
    identified through RSA's review process, and work with RSA and State VR
    agencies to develop plans for addressing those needs. The TACE Centers
    are supported by a Technical Assistance (TA) Network consisting of
    other RSA- and NIDRR-funded projects focused on VR and employment.
    Program Improvement Funds Projects Supporting Technical Assistance to
            State VR Agencies
        Program Improvement funds provided under section 12 of the
    Rehabilitation Act are being used to support technical assistance
    activities, including a National Vocational Rehabilitation Technical
    Assistance Center (NTAC) that coordinates the activities of a TA
    Network that supports technical assistance and continuing education
    activities for State VR agencies. Nearly half (47 percent) of the funds
    would be used to continue support for the NTAC. Program improvement
    funds will also be used to increase service delivery capacity by
    providing forums for sharing promising practices, and by enhancing the
    capacity of grantees to fulfill their responsibilities more effectively
    and efficiently. Timely training and technical assistance will be
    delivered to RSA grantees and stakeholders using state-of-the-art
    communication methods as the primary means of dissemination, including
    web-based seminars (webinars), and RSA's new Dissemination and
    Technical Assistance Resource web-based resource. These strategies will
    allow RSA to reach a broader population of grantees and stakeholders
    without convening face-to-face meetings, greatly improving the cost
    effectiveness of providing ongoing training and technical assistance.
    Evaluation Funds Support Studies To Improve Program Performance
        Evaluation funds provided under section 14 of the act are also
    being used to conduct studies that will assist the Department to
    improve program performance. Additional information on these and other
    related projects and activities are provided on pages J-80 to 89 of
    Volume I of the Department of Education fiscal year 2010 Justification
    of Appropriation Estimates to Congress.
    Improving Quality of Program Employment Outcomes
        State VR agencies are serving more individuals with particularly
    challenging disabilities and personal histories, including, but not
    limited to, more individuals who are autistic, experience chronic
    mental illness, battle substance abuse, or have criminal records. New,
    innovative, and effective approaches are needed in order for VR
    agencies to improve the quality and quantity of the program's
    employment outcomes. Through NIDRR, the Department is supporting
    employment-related centers and projects that will identify and develop
    evidence-based practices that have been proven effective in improving
    employment outcomes for these and other challenging and emerging
    populations. The results of these investments will be disseminated to
    VR counselors and VR service providers to assist in their efforts to
    increase the number of individuals with disabilities that achieve and
    sustain employment.
    Fiscal year 2010 Support for Projects on Employment and Vocational
            Rehabilitation of Individuals With Disabilities
        The fiscal year 2010 budget request would support research centers
    and projects initiated in previous years and new projects that focus on
    employment and vocational rehabilitation of individuals with
    disabilities.
        NIDRR will continue support for the following employment research
    centers and projects:
      --Center on Demand-Side Employment Placement Models (fiscal year
            2006).
      --Center for Vocational Rehabilitation Research (fiscal year 2007).
      --Vocational Rehabilitation Service Models for Serving Individuals
            with Autism Spectrum Disorders (fiscal year 2008).
      --Center on Vocational Rehabilitation Program Management (fiscal year
            2009).
      --Center on Effective Delivery of Rehabilitation Technology by
            Vocational Rehabilitation Agencies (fiscal year 2009).
      --Center on Improved Employment Outcomes for Individuals with
            Psychiatric Disabilities (fiscal year 2009).
        Examples of new employment-related topics that are under
    consideration for NIDRR support in fiscal year 2010 include:
      --Individual-level Characteristics Related to Employment Among People
            with Disabilities.
      --Transition to Employment.
      --Knowledge Translation of Employment Research Findings.
      --Employer Practices Related to Employment Outcomes.
      --Employment Measurement and Policy.
      --Employment Outcomes for Individuals with Blindness and Low Vision.
    Vocational Rehabilitation Strategic Performance Plan
        Finally, RSA is developing a Vocational Rehabilitation Strategic
    Performance Plan, including goals, objectives, and outcome-oriented
    performance measures, to ensure a long-term strategic focus on program
    performance, performance improvement, and outcomes for individuals with
    significant disabilities. The plan will assist the Department in
    directing its resources (monitoring, technical assistance, training,
    demonstration, and evaluation) toward the implementation of policies
    and practices that are known to have a positive effect on increasing
    high-quality employment outcomes. RSA will use this plan to guide the
    administration of the VR program and address program challenges. The
    plan will assist RSA in monitoring progress of the VR program and to
    provide appropriate, targeted technical assistance to State agencies
    toward the achievement of desired outcomes.
             findings from monitoring reviews of state vr agencies
        Question. What are the major categories of findings from State VR
    reviews and the technical assistance provided to help State VR agencies
    implement corrective action plans?
        Answer. Many of the findings from the reviews of State VR agencies
    often center on fiscal management, implementation of an order of
    selection for services (if a State agency does not have sufficient
    resources to serve all eligible individuals), and delays in service
    provision. When findings are identified, State VR agencies develop a
    corrective action plan (CAP) describing how they will address the
    findings. RSA then monitors the implementation of the plan until it is
    complete. If the compliance finding relates to a failure to meet one of
    the standards and indicators, the VR agency develops a program
    improvement plan (PIP) and RSA monitors the agency's progress toward
    improving its performance. In addition to compliance findings, RSA
    makes observations and recommendations to improve the performance of
    State VR agencies. Recommendations often focus on such issues as
    improving the VR agencies employment outcome rate, increasing the
    number of individuals applying for the program, improving the agency's
    case management system, strengthening the agency's management of data,
    implementing a comprehensive strategic planning process, improving
    internal and external communications, and developing and implementing a
    quality assurance system. RSA also provides technical assistance both
    during and after monitoring visits to assist State agencies in
    addressing compliance findings or to implement a recommendation.
    Furthermore, the TACE Centers provide additional technical assistance
    upon request.
                        delivery of technical assistance
        Question. On average, how long does it take to complete delivery of
    technical assistance to address State needs?
        Answer. The duration of technical assistance depends on the type
    and complexity of the need as well as when, how, and by whom the
    technical assistance is delivered. RSA offers on-site technical
    assistance during its reviews of State agencies, so that the delivery
    of some technical assistance is immediate or completed in a few days.
    RSA also has used annual fiscal and data management meetings to deliver
    technical assistance directly to agency personnel over the course of 2
    days. If a State agency has a PIP or CAP, the plan includes timelines
    for its completion and RSA may provide technical assistance at any
    point during that timeline.
        The TACE Centers program provides longer-term and more systemic
    technical assistance. The TACE program was recently implemented and RSA
    does not yet have data on how long it takes the Centers to complete the
    delivery of technical assistance to States. The Centers submitted plans
    to RSA at the beginning of fiscal year 2009 describing the needs to be
    addressed and the activities the TACE will conduct to address them,
    including projected timelines for completion. The projected time for
    TACE Centers to complete technical assistance varies based on the
    complexity of the need or intervention. For example, assisting a State
    agency to create and launch a quality assurance system where none
    existed may take significantly longer than assisting a State agency to
    create a strategic plan for addressing personnel shortages. As such,
    according to TACE Center plans, the range of duration for technical
    assistance is anywhere from a few months to 2 years depending on the
    need.
       improvement of deficiencies identified in state monitoring reviews
        Question. Has the technical assistance, at least in part, led to
    improvement of the deficiencies identified in VR reviews?
        Answer. Yes. Over the past 3 years, State VR agencies have made
    steady progress in completing corrective actions and taking steps to
    improve their performance as a result of RSA's technical assistance
    efforts. RSA provides technical assistance during and following its
    State monitoring reviews. RSA tracks State VR agency progress and
    completion of corrective actions outlined in either a CAP or a PIP.
    They also track a State agency's progress toward implementing
    recommendations aimed at improving performance. As of this time, RSA's
    technical assistance efforts have produced the following results:
      --60 agencies have completed all of their required corrective actions
            that resulted from previous monitoring reviews, and 20 State VR
            agencies are implementing approved corrective actions plans
            resulting from fiscal year 2007 and fiscal year 2008 reviews;
      --During the on-site portion of RSA's reviews, agencies have
            corrected a significant number of deficiencies relating to
            reporting and fiscal management requirements; and
      --RSA received 84 requests for technical assistance from State VR
            agencies to address performance and compliance deficiencies
            identified during its fiscal year 2008 reviews of 19 State
            agencies. RSA is either providing that TA directly or is
            working with the TACE Centers to provide agencies with the
            technical assistance they requested.
        RSA has also developed an informal evaluation survey that State VR
    agencies and other stakeholders are requested to complete after a
    monitoring review. The vast majority of comments received indicate that
    the reviews are helpful and that the technical assistance is timely and
    consistent.
            resources for reviews of centers for independent living
        Question. Are sufficient resources available in the current year
    and fiscal year 2010 budget request to conduct the 20 compliance
    reviews of Centers for Independent Living (CILs) required by the
    Rehabilitation Act?
        Answer. The RSA has sufficient resources to conduct 20 on-site
    compliance reviews of the CILs in 2009 and in 2010. In addition, RSA
    uses performance information that is collected annually to monitor CIL
    performance and compliance with established standards and indicators.
            technical assistance for centers for independent living
        Question. What resources are available in the current year and
    under the fiscal year 2010 budget request to provide technical
    assistance to CILs?
        Answer. In accordance with section 721(b) of the Rehabilitation
    Act, RSA is setting aside $2,965,788 of the funds appropriated for
    fiscal year 2009 under title VII, chapter 1, part C of the
    Rehabilitation Act, including $1,575,000 in Recovery Act funds, for
    training and technical assistance to CILs and statewide independent
    living councils (SILCs). Of this amount, $1,465,485 will be used to
    provide continuation funding for three grants, two of which provide
    training and technical assistance to CILs and one of which provides
    these services for SILCs. Funds remaining after funding the
    continuation awards will be used for new competitive awards, an
    estimated $1,325,000 of which would be used to support training and
    technical assistance to CILs. Under the budget request for fiscal year
    2010, $1,444,788 would be set aside for training and technical
    assistance to CILs and SILCs. The CILs are also eligible to receive
    technical assistance from the Technical Assistance and Continuing
    Education centers.
        Question. Are these resources sufficient to meet the requirement
    under the Rehabilitation Act?
        Answer. The allocations outlined above are sufficient to comply
    with the requirement in section 721(b) of the Rehabilitation Act that
    RSA reserve no less than 1.8 percent and no more than 2 percent of
    funds appropriated under title VII, chapter 1, part C of the Act for
    CIL and SILC training and technical assistance.
                         career and technical education
        Question. A 2005 National Research Center for Career and Technical
    Education report found that a ratio of 1 CTE class for every 2 academic
    classes minimizes the risk of students dropping out of school. What
    role does the Department believe career and technical education courses
    funded under the Perkins Career and Technical Education Act have in
    working to support the administration's goal of decreasing the dropout
    rate, and contributing to the administration's high school reform
    efforts?
        Answer. We know that many youth drop out of high school because
    they are not challenged and they do not feel their courses are relevant
    to their future careers and ambitions. Career and technical education
    (CTE) courses provide students with the information, training, and
    skills that are relevant to future careers, thus potentially making all
    of their classes more meaningful. As you have noted, we know that CTE
    courses can provide students, particularly those at risk of dropping
    out of school, with the motivation and justification for staying in
    school. According to the NCES report CTE in the United States: 1990 to
    2005, students who take CTE courses in high school are likely to pursue
    postsecondary education. The 2006 reauthorization of the Perkins Act
    increased the Act's emphasis on the rigor of CTE courses and created
    the requirement that States create at least one ``program of study,''
    which, among other things, must include coherent and rigorous content
    aligned with challenging academic standards and must incorporate
    secondary and postsecondary elements. As such, the CTE program will
    continue to support the Administration's goal of decreasing the dropout
    rate by supporting high school reform efforts that make coursework more
    coherent, challenging, and relevant to postsecondary education,
    training, and the workforce.
                 intergovernmental job training programs review
        Question. The Congressional Budget Justification indicates that the
    administration is conducting a comprehensive review of job training
    programs to assess their effectiveness. What is the Department's
    timeline for completing action on this review?
        Answer. In preparation for the upcoming reauthorization of the
    Workforce Investment Act (WIA), the Department has been working with
    the Department of Labor, Domestic Policy Council, and Office of
    Management and Budget to review job training programs administered by
    both agencies. The goal is to ensure that education and labor programs
    work together effectively at the local level to provide seamless career
    advancement services for low-skilled adults, at-risk youth, and others
    needing employment and training. The review will inform the
    administration's policies on reauthorization of the WIA as well as
    budget policies in the President's 2011 budget request.
        Question. What actions (and associated findings) have been
    completed to date?
        Answer. The Office of Management and Budget has convened meetings
    with the Department of Education, Department of Labor, and the Domestic
    Policy Council to discuss the existing job training programs and the
    process for developing a reauthorization proposal.
                        national institute for literacy
        Question. The fiscal year 2010 budget request proposes to eliminate
    funding for the National Institute for Literacy (NIFL). The
    Congressional Budget Justification indicates that the NIFL resources
    would be absorbed by the Department, which would continue NIFL
    activities that are of value to the field. How will the Department
    determine which activities to continue?
        Answer. The Department has begun to organize meetings in order to
    learn more about the needs of the adult literacy and adult education
    communities. Once we have completed that process, we will review the
    existing NIFL activities and determine which of them still meet a
    current need and, of those, which could be subsumed within existing
    projects in the Department and which need to be continued regardless of
    the vehicle. NIFL's current system of delivery, LINCS, will be part of
    this review. In addition, the Department has already heard from the
    adult literacy and adult education field that there is a desire to
    create a new center on adult literacy and education. The center could
    provide many of the services that are authorized for NIFL under the
    WIA.
        Question. Which National Institute for Literacy activities are
    continued with resources available in the fiscal year 2010 budget
    request?
        Answer. The Department will need to complete a review of NIFL's
    existing activities in order to determine which activities should be
    continued. The funds appropriated for NIFL are multi-year funds. NIFL
    has not yet begun to expend its fiscal year 2009 funds and will have
    access to its fiscal year 2009 appropriation through September 30,
    2010. This provides the Department with ample time to review the fiscal
    year 2010 appropriations and make decisions about the activities to
    continue, initiate, or terminate.
                    research on adult education and literacy
        Question. Roughly 30 million adults have educational issues that
    make difficult their pursuit of education, occupational training, and
    securing or retaining a job. Specifically, how much research,
    development, and dissemination funding has IES previously dedicated to
    specific funding opportunities to support rigorous research on programs
    and strategies designed to help adults develop the reading and writing
    skills they need to be successful in school and/or work?
        Answer. The following chart includes grants and cooperative
    agreements, including award amounts, awarded by the IES for research
    projects that focus on the development of reading and writing skills in
    adult students. IES would have made additional awards on this topic if
    more applications had been judged to be of higher quality by peer
    reviewers. Approximately 30 percent of the funding of the National
    Center on Postsecondary Research is devoted to research related to
    helping adults develop reading and writing skills. Other grants shown
    are exclusively on this topic.

                                        RESEARCH ON ADULT EDUCATION AND LITERACY
    ----------------------------------------------------------------------------------------------------------------
            Title of research project                    Grantee                        Year                Amount
    ----------------------------------------------------------------------------------------------------------------
    Improving Adults' Reading Outcomes with    Daryl Mellard/University of  2007.......................   $1,991,961
     Strategic Tutoring and Content             Kansas.
     Enhancement Routines
    Postsecondary Content-Area Reading-        Dolores Perin/Teachers       2006.......................    1,168,758
     Writing Intervention: Development and      College, Columbia
     Determination of Potential Efficacy        University.
    The Writing Pal: An Intelligent Tutoring   Danielle McNamara/           2008.......................    2,015,456
     System that Provides Interactive Writing   University of Memphis.
     Strategy Training
    Assessing Reading Comprehension with       Joseph Magliano/Northern     2004.......................    1,560,506
     Verbal Protocols and Latent Semantic       Illinois University.
     Analysis
    Developing Reading Comprehension           John Sabatini/Educational    2004.......................    1,572,635
     Assessments Targeting Struggling Readers   Testing Service.
    Developing a Program of Postsecondary      Stephen Steurer/             2007.......................    1,997,936
     Academic Instruction Over the              Correctional Education
     Corrections Learning Network               Association.
    The Effects of College Remediation on      Isaac McFarlin/University    2007.......................      301,687
     Students' Academic and Labor Market        of Texas, Dallas.
     Outcomes
    National Center for the Study of Adult     John Comings...............  1996 (to 2007).............   30,191,490
     Learning and Literacy (http://
     www.ncsall.net/?id=1)
    National Center for Postsecondary          Thomas Bailey..............  2006.......................    9,813,619
     Research (http://
     www.postsecondaryresearch.org)
    ----------------------------------------------------------------------------------------------------------------

            major findings of research on adult reading and writing
        Question. What have been the major activities/findings supported by
    this funding?
        Answer. Research on programs and practices to help adults develop
    their reading and writing skills has been funded through three
    mechanisms: (a) reading and writing research programs, (b) the
    postsecondary education research program, and (c) the national research
    and development center program.
    Reading and Writing Research Programs for Adult Learners
        IES has solicited applications for research on improving reading
    outcomes for adult learners through its research programs on reading
    and writing since 2002, but it has received relatively few applications
    for research on this topic despite the need for flexible and
    appropriate interventions for adult learners and for materials that
    enable adult education instructors to teach reading to underprepared
    adults. In order to stimulate more interest in research on this topic,
    in 2007, IES created a separate research program called ``Interventions
    for Struggling Adolescent and Adult Readers and Writers.''
        To date, five research projects on adult literacy have been
    awarded. IES-funded researchers at the University of Kansas are
    developing interventions for Job Corps participants that focus both on
    mastering literacy skills and on developing the knowledge and skills
    needed to pass the vocational certification tests. A team at Teachers
    College is working to improve interventions for community college
    students in remedial reading classes. University of Memphis researchers
    are developing a computer tutor that adults can use to support their
    mastery of writing. The remaining grant on this topic supports the
    development of assessments for use with adult readers and writers. The
    assessment of adults has provided ongoing challenges, both because the
    content of typical reading assessments is inappropriate for adults, and
    because current assessments do not provide sufficient discrimination at
    the low ability end. IES is supporting the development of two new sets
    of assessments to address these issues.
    Improving Reading Outcomes for Adults Underprepared for Postsecondary
            Education
        IES has funded research on improving reading outcomes for adults
    who are underprepared for postsecondary education through its
    postsecondary education research program. The researchers on one of the
    grants are evaluating the impact of a satellite-based distance learning
    program for prisoners aged 18-25 on the adults' academic achievement,
    progress toward a degree, recidivism, and subsequent workforce
    participation. The results of this evaluation are not yet available. A
    second project examines the effects of remediation courses on
    postsecondary students in Texas and Florida. Initial results have found
    existing remedial education programs to have no benefits for Texas
    students attending 2- or 4-year institutions in regards to academic
    credits attempted, likelihood of completing 1 year of college, degree
    completion, transferring to a 4-year college, or labor market earnings.
      national research and development centers research on adult literacy
        Through grants from IES, two national research and development
    centers, the National Center on Postsecondary Research and the National
    Center for the Study of Adult Learning and Literacy, have addressed
    adult literacy challenges. From 1996 to 2007, the Department of
    Education, through Office of Educational Research and Improvement and
    then IES, supported the National Center for the Study of Adult Learning
    and Literacy (NCSALL). NCSALL conducted primarily descriptive research
    highlighting the diversity of individuals being served by adult
    literacy instruction, characteristics of adult basic education
    teachers, and social and instructional processes that occur in adult
    education classes. In addition, NCSALL engaged in dissemination of
    information to practitioners.
        The National Center for Postsecondary Research (NCPR) is measuring
    the effectiveness of programs designed to help students master the
    basic skills needed to advance to a degree. Their broad program of
    research includes two projects that specifically target reading skills
    for underprepared postsecondary students. The first study examines the
    impact of remedial English courses in community and 4-year colleges and
    has found that remediation improved persistence among Florida community
    college students but did not increase the likelihood of course
    completion, transfer to a 4-year school, or degree completion. The
    other project (no findings yet) focuses on the use of learning
    communities (some specifically target reading or English) in community
    colleges.
        Although there is a great need for additional rigorous research in
    this area, the current capacity of the field to carry out this research
    is limited. In order to rectify this, IES continues to reach out to the
    adult education research community and to stimulate interest in adult
    education research on the part of researchers who have conducted
    rigorous research on K-12 students.
               funding for research on adult reading and writing
        Question. How much funding is allocated to adult reading and
    writing research in the current year, as well as under the budget
    request?
        Answer. The number of grants IES awards in any year depends on the
    number of high-quality applications received under a specific program,
    such as the research program on Interventions for Struggling Adolescent
    and Adult Readers and Writers. No new applications for research on
    adult reading and writing were awarded in 2009 because IES did not
    receive any applications in 2009 that peer reviewers determined
    warranted support. Ongoing projects are receiving support. IES is
    unable to predict how much funding will be allocated to adult reading
    and writing research in 2010, but the budget request for 2010 is
    sufficient to fund all applications on this topic that peer reviewers
    judge to be of high quality.
                            what works clearinghouse
        Question. Last year, in response to concerns raised about the
    operation of the What Works Clearinghouse (WWC), the National Board on
    Education Sciences convened an expert panel to perform a focused study
    addressing the fundamental question of whether the Clearinghouse's
    evidence review process and reports are scientifically valid. The panel
    report found that is generally the case, but made a number of
    recommendations, including that the Department of Education commission
    a comprehensive review of the full range of WWC activities and
    procedures, with a timeframe to allow a complete consideration of a
    number of issues that could not be fully evaluated in the Expert Panel
    report. What action is IES taking in and/or planning for the current
    fiscal year and fiscal year 2010 to address these recommendations?
        Answer. The WWC and its statistical team are currently considering
    how the WWC standards should take into account study size and other
    issues noted by the expert panel. The WWC released a Procedures and
    Standards Handbook [Version 2.0] in December 2008 as a result of the
    panel's report. A comprehensive review of the full range of WWC
    activities and procedures and of its other dissemination activities
    will be a high priority for IES and its new leadership as it begins to
    consider reauthorization of the Education Sciences Reform Act and the
    development of a statement of work for the next competition for the WWC
    contract.
                     program administration staff increases
        Question. The fiscal year 2010 budget proposes a net increase of 58
    full-time equivalent staff (FTEs) above the 2009 level for key
    positions not staffed in 2009 due to funding constraints and to
    implement the Recovery Act. The Congressional Budget Justification
    identifies 7 FTEs in the Office of Elementary and Secondary Education
    needed for Recovery Act implementation. Please identify the positions
    not staffed in 2009 due to funding constraints, as well as the impact
    of not staffing these positions in 2009 and in 2010.
        Answer. The additional staff requested in fiscal year 2010 are
    necessary to perform several key functions not performed at optimal
    levels in 2009 due to funding constraints. These functions are grouped
    into the four areas listed below.
        The first function requiring additional staff is monitoring grants
    awarded by the Department in a variety of areas including elementary
    education, postsecondary education, and in programs grants focusing on
    providing services to individuals with disabilities. Additional
    monitoring is needed to ensure that Department programs are both
    improving the quality of education and are fiscally sound.
        Additional staff are also needed to work on increasing college
    access and student success by restructuring and dramatically expanding
    Federal financial aid, while making programs simpler, more reliable,
    and more efficient. A key component of this effort is to simplify the
    Federal application for student aid--Free Application for Federal
    Student Aid (FAFSA)--making it easier to complete and more effective
    for students.
        Increased staff will also work on the administration's priorities
    related to reauthorization of the ESEA and the WIA.
        Finally, staff are needed for the Department's staff offices to
    work on activities including budgeting, legislative affairs, public
    outreach, and policy formulation.
                     recovery act administrative activities
        Question. The Recovery Act required Department staff to take many
    actions this budget year, including developing and issuing guidance
    documents, allocating funds, and writing requests for proposals,
    without additional resources. What specific activities would be
    undertaken with these requested funds?
        Answer. For several Recovery Act programs, such as the State Fiscal
    Stabilization Fund, Teacher Incentive Fund, and Impact Aid, the
    Department received appropriated funds for the purpose of
    administration and oversight. For Recovery Act programs without any
    administration and oversight funds, the Department has included funds
    necessary for this purpose in its fiscal year 2010 program
    administration budget request. ARRA-specific administration and
    oversight activities include policy development, grant award (either
    through allocation or grant competition), technical assistance--
    ensuring that grantees effectively and properly use their funds, grant
    reporting, and grant monitoring. In many cases, the Department assumed
    these activities would be covered with existing resources and staff
    time.
    compliance and technical assistance activities in the office for civil
                                     rights
        Question. Over the last decade, more than half of the Office for
    Civil Rights' (OCR) complaint receipts have alleged disability
    discrimination. Please explain the compliance and technical assistance
    activities that OCR is taking currently or planning to undertake in the
    current budget year and fiscal year 2010.
        Answer. Shown below is a list of the 29 fiscal year 2009 compliance
    reviews conducted by OCR. Also shown below is a list of the fiscal year
    2009 planned technical assistance activities. More than 100 technical
    assistance presentations have already been done by OCR on the issues
    listed, some initiated by OCR and others requested by recipients or
    interested other parties such as parent groups or students. In
    addition, OCR does other technical assistance as requested.
        Concerning the compliance reviews and technical assistance
    activities that OCR plans to conduct in fiscal year 2010, those plans
    are being developed now.
    Fiscal year 2009 OCR Compliance Reviews
        Fiscal year 2009 OCR Compliance Reviews:
      --Providence Public Schools (RI)
        Title VI: English Language Learners services, Limited English
    Proficient parent communication
      --Sachem Central School District (NY)
        Section 504/ADA: Coordinator, grievance procedures
      --Hempstead Union Free School District (NY)
        Section 504/ADA: Coordinator, grievance procedures
      --New York City Department of Education, P.S. K396 (NY)
        Section 504/ADA: Implementation of individual education programs
      --New York City Department of Education, P.S. M094 (NY)
        Section 504/ADA: Implementation of individual education programs
      --College of Notre Dame (MD)
        Title IX, Section 504/ADA: Coordinator, grievance procedures
      --Hood College (MD)
        Title IX, Section 504/ADA; Coordinator, grievance procedures
      --Cleveland County (SC)
        Title IX: Athletics
      --Hillsborough County School District (FL)
        Title IX: Sexual harassment policies and procedures
      --St. Lucie County School District (FL)
        Section 504/ADA: Disparate discipline
      --Painesville City Local School District (OH)
        Title VI: English Language Learners services
      --Notre Dame College (OH)
        Title IX: Sexual harassment policies and procedures
      --Eastern Michigan University (MI)
        Title IX: Sexual harassment policies and procedures
      --Moline School District (IL)
        Title VI: English Language Learners services, Limited English
    Proficient parent communication
      --Ball State University (IN)
        Title IX: Athletics
      --Bayless School District (MO)
        English Language Learners services
      --Cape Girardeau #63 School District (MO)
        Section 504/ADA: Physical accessibility
      --South Brown County U.S.D. #430 (KS)
        Title VI: National origin-based harassment, different treatment
      --Jenks Public Schools (OK)
        Section 504/ADA: Implementation of individual education programs
      --Texas A & M University (TX)
        Title IX, Section 504/ADA, Grievance procedures
      --Campbell County School District (WY)
        Section 504/ADA: Coordinator, grievance procedures
      --Churchill County School District (WA)
        Title IX: Athletics
      --Idaho Falls School District 91 (ID)
        Title IX: Athletics
      --Seattle School District No. 1 (WA)
        Title VI: School closings
      --University of Montana (MT)
        Section 504/ADA: Physical accessibility
      --University of Montana-Western (MT)
        Section 504/ADA: Physical accessibility
      --Mt. Diablo Unified School District (CA)
        Title VI: English language learners services
      --Ontario-Montclair Elementary School District (CA)
        Title VI, Section 504/ADA: Placement of English Language Learners
    in special education
      --Vallejo Unified School District (CA)
        Title VI: Race-based disparate discipline
    Fiscal year 2009 Planned OCR Technical Assistance Activities
        Fiscal year 2009 Planned OCR Technical Assistance Activities:
        The list that follows is only the list of subjects that OCR planned
    to address in fiscal year 2009.
        Section 504 /ADA:
      --Identification and evaluation of students;
      --TA to postsecondary institutions whose Web sites are inaccessible
            to individuals with disabilities;
      --Transition of students with disabilities from high school to
            postsecondary institutions;
      --Training to elementary and secondary special education directors
            and 504 coordinators;
      --TA to postsecondary institutions and veterans concerning services
            for disabled veterans;
      --Procedural safeguards and impartial hearing process;
      --Academic adjustments and auxiliary aids; and
      --Students with disabilities in college.
        Title IX:
      --Grievance procedures and responsibilities of Title IX coordinators;
            and
      --Sexual harassment.
        Title IX: Athletics (postsecondary)
        Title VI:
      --Limited English proficiency
        Early Complaint Resolution:
      --TA to promote the use of ECR by complainants and recipients.
       proposed organizational placement of office of civil rights staff
                                   increases
        Question. How will the additional 19 FTEs in the fiscal year 2010
    budget request be deployed with respect to its organization and
    mission?
        Answer. The 19 FTE will restore OCR's staff to a level necessary to
    fulfill its mission, and ensure successful management of OCR programs
    and priorities. Sixteen FTE will be assigned to OCR's regional offices
    for resolving complaints and compliance reviews, and three FTE will be
    used in headquarters for developing policy guidance and technical
    assistance materials.
                                     ______

                  Questions Submitted by Senator Patty Murray
                           early childhood education
        Question. President Obama included $7.2 billion for Head Start in
    his budget, which is actually a decrease from the fiscal year 2009
    regular appropriations level, not including stimulus funding. While I
    am pleased that the significant recovery funding for Head Start
    programs is starting to help our State and local communities who are
    struggling, I know that a strong, sustained investment in Head Start is
    the only way that this program can continue to be effective,
    particularly in light of the improvement and coordination tasks we have
    asked Head Start programs to take on as part of reauthorization. Do you
    plan to increase funding for Head Start programs in future years, when
    stimulus funding has ended?
        Answer. Since the Head Start program is administered by the
    Department of Health and Human Services, Secretary Sebelius would be
    better suited to answer your question.
                         early learning challenge fund
        Question. How does your $300 million early learning challenge grant
    proposal connect to existing Federal and State funding streams such as
    Head Start, child care, pre-K, and their K-12 systems?
        Answer. The new Early Learning Challenge Fund would serve to
    improve the quality of existing and proposed Federal investments in
    early childhood programs, including Head Start, by funding State
    efforts to develop a statewide infrastructure of integrated early
    learning supports and services for children. With this framework in
    place, States would be able to compare the quality of services for
    children from birth through age 5 without regard to funding source,
    which would also inform Federal and State decisionmaking regarding
    investments in early learning.
        Question. How will the grants encourage recipient States to take
    high-quality pre-K to a larger scale and build an early childhood
    system around a strong and successful program?
        Answer. The grants would support State efforts to improve the
    quality of existing early childhood services by holding all publicly
    funded programs to a common set of State-developed standards. The
    administration expects that this effort would build a pathway for
    increased Federal, State, and local investments in high-quality early
    childhood programs in the coming years.
                        literacy--early reading programs
        Question. I was excited to see that the President included funding
    for early and adolescent literacy grants in the fiscal year 2010 budget
    proposal. In the last session of Congress, I introduced a literacy
    bill, called the Striving Readers Act, along with my colleague Senator
    Sessions. A companion bill passed on the House side last year. There is
    clearly bipartisan interest here in Congress for creating an improved
    adolescent literacy program, hopefully as part of a comprehensive
    literacy program for young children all the way through grade 12.
        Can you tell us a little bit more about what this literacy program
    would look like and why the administration chose to include both
    adolescent and early literacy grants in the proposal?
        Answer. The administration's request for the Striving Readers Act
    included an increase both to build on the success of the current
    Striving Readers program, which focuses on adolescent literacy, and to
    enable schools to implement innovative and effective strategies for
    improving the reading comprehension of students in low-income
    elementary schools. We structured the request to emphasize the
    importance of continued investment in high-quality literacy programs
    from elementary school through high school, and also to invoke an
    existing authority to request funds for early reading services that
    would draw lessons from and addresses the deficiencies of Reading First
    and other literacy efforts. Applicants would be required, at a minimum,
    to serve students in grades kindergarten to third grade and would be
    encouraged to extend services to children in pre-kindergarten and in
    the fourth or fifth grades. Applicants would also be required to
    demonstrate how they would coordinate their reading programs from
    preschool through fifth grade, including with activities supported with
    funds from other Federal, State, or local sources. The Department would
    require participating schools to incorporate proven practices into
    their programs, including by providing a significant amount of time
    focused exclusively on reading instruction as well as integrating
    reading instruction into other content areas across the curriculum.
              federal support for early learning literacy programs
        Question. Do you see a strong continued role for Federal support of
    kindergarten through grade three literacy programs in States?
        Answer. Research shows that early reading skills are a major
    predictor of future success in school. We do believe that the Federal
    funds should be used support high-quality literacy programs. This is
    why the administration included $300 million for early reading in the
    budget request.
        Question. Do I have your commitment to work together on this
    literacy proposal to ensure that we have the best continuum of literacy
    supports possible for our youth?
        Answer. I look forward to having these discussions with you in the
    coming months.
    adult literacy programs and reauthorization of the workforce investment
                                      act
        Question. What is your vision for adult literacy, for those who may
    not yet have gained the skills they need to be successful in the
    workforce?
        Answer. The reauthorization of the Workforce Investment Act (WIA)
    provides an opportunity for the administration to look carefully at the
    needs of low-literate adults. The Departments of Education and Labor
    envision a modernized service delivery system that provides seamless
    support for adults who seek employment, regardless of their needs. This
    system would provide integrated solutions to meet the needs of both
    workers and employers. The Department of Education currently envisions
    a reauthorized WIA that leads to all States having adult education
    standards that are aligned with standards for college and career
    readiness. Finally, the Department of Education believes that the adult
    education and adult literacy communities must identify successful
    practices for meeting the needs of the diverse groups of adult
    learners, such as adults with limited English proficiency, youth at
    risk of dropping out of school, and adults who have not attained the
    requisite skills needed for jobs that will enable them to support
    themselves and their families.
                     data collection and the sdfsc program
        Question. Secretary Duncan, as you know the administration has
    proposed to move all of the SDFSC State Grant funding into national
    programs.
        It is my understanding that the Department of Education under the
    last administration did very little to collect data under the SDFSC
    program, although these data collection efforts are specifically
    required by law. Why is the administration not taking the first step of
    fully honoring data collection and accountability requirements and
    examining the new data on whether this program works as a State grant
    before moving all of the funding to national efforts?
        Answer. The Elementary and Secondary Education Act of 1965 requires
    that each State participating in the SDFSC State Grants program
    implement a Uniform Management Information and Reporting System (UMIRS)
    and make information about drug and violence prevention programs
    available to the public. Specifically, the UMIRS provisions require
    that States report information about truancy rates and drug- and
    violence-related offenses resulting in suspensions or expulsions. These
    data are required to be reported at the school-building level.
    Additionally, States must also report information about types of
    curricula, programs, and services provided with SDFSC State Grants
    program funds, and information about incidence and prevalence, age of
    onset, perception of health risk and perception of social disapproval
    of drug use and violence. We have monitored State implementation of the
    UMIRS requirements during the past several years and have not
    identified significant instances of noncompliance.
        The SDFSC program also requires that States provide reports about
    their implementation and outcomes of programs supported with State
    Grants program funds, as well as information about their progress in
    attaining identified performance measures, and on the State's efforts
    to inform parents of and include parents in drug and violence
    prevention efforts.
        We have collected some of this information from States as part of
    the Consolidated State Performance Report (CSPR). In an effort to
    minimize data collection and reporting burden for the States, we
    requested data from States only about truancy and suspensions and
    expulsions for drug- or violence-related offenses--information that
    States are required by the UMIRS provisions. States have also reported
    their progress toward meeting the performance measures they identified
    for the program.
        The statute does not create a unified system of data collection and
    reporting; rather it requires that each State create its own, uniform
    system. Because we believe that it would be valuable for States to
    collect and report the required data in a manner that is more uniform
    across the States, we have worked with States to identify a uniform
    data set that includes common definitions and collection protocols for
    data required by the UMIRS requirements. We are beginning to use those
    definitions and protocols in CSPR collections, but the definitions and
    protocols are voluntary.
        statutory funding requirements under sdfsc state grants program
        We believe that we have implemented the statutory requirements of
    the current authorization, but continuing concerns about the SDFSC
    State Grants program stem not just from the challenges involved in
    collecting and aggregating meaningful outcomes data for the program.
    The most significant concern is the current structure of the program,
    which requires that funding be distributed to any local school
    districts that wish to participate. Even when program funding levels
    were significantly greater than they are now, such as in fiscal year
    2004 (2004-2005 school year), fully two-thirds of participating school
    districts (67 percent) received less than $10,000 under the program.
    Realistically, grants of this size are not sufficient to permit
    districts to adopt and implement high-quality programs for even a small
    proportion of their students.
      funding support for drug and alcohol abuse prevention and violence
                              prevention programs
        Question. With State and local budgets strained or massively cut
    back across the Nation, if a local educational agency (LEA) does not
    receive funding under the proposed new funding for the national
    program, how does the administration expect that this district will
    continue their efforts to prevent drug and alcohol abuse and prevent
    violence among students? I believe this question is particularly
    important in a time of economic crisis when we tend to see an increase
    in concerning activities among youth and families.
        Answer. As your question suggests, many States and localities are
    experiencing the most significant economic challenges in memory, and
    the result is that policy makers at all levels of government are being
    forced to make very painful choices about where to spend a declining
    pool of revenues. Just as State and local officials are reviewing
    expenditures very closely and establishing priority uses for limited
    available funding, the administration engaged in a similar process in
    developing the President's fiscal year 2010 budget request. Ultimately,
    we had to identify program terminations or consolidations in order to
    reduce spending. Part of the process for formulating the fiscal year
    2010 budget included reviewing available information about program
    effectiveness or other analyses that point to problems that may limit a
    program's capacity to produce desired outcomes. Findings from recent
    assessments of the program and from the Rand study suggested that the
    SDFSC program is not currently structured in a way that is likely to be
    able to demonstrate significant student outcomes.
        I share your concern about the importance of preventing drug and
    alcohol use and violent behavior among students and know both of these
    behaviors not only imperil students, but also pose significant barriers
    to student academic achievement. We are anxious to make the best
    investments we can in order to address these problems, and believe that
    the new $100 million initiative to improve school culture and climate
    (included in the fiscal year 2010 budget request under SDFSC national
    programs) provides the best opportunity in the current economic climate
    to make a meaningful difference in a significant number of schools and
    communities.
        Support provided under the State Fiscal Stabilization Fund (SFSF),
    part of funding appropriated under the American Recovery and
    Reinvestment Act of 2009, may also be a potential source of support for
    drug and violence prevention programs and activities. Monies available
    to States under either component of the SFSF program--the Education
    Stabilization Fund or the Government Services Fund--may be used to
    support a broad range of educational services and activities, including
    prevention programming, in elementary and secondary school settings.
                technical assistance for leas for sdfsc programs
        Question. How will technical assistance and training be
    consistently provided to LEAs without the State assisting with that
    role, and does the Department of Education have the capacity to take on
    this role?
        Answer. The Department will continue to provide some technical
    assistance to States relating to safe and drug-free schools, but lacks
    both the funding and staffing to become a primary provider of technical
    assistance directly to schools, school districts, and communities
    across the country. Several States have developed and maintain school
    safety centers or other technical assistance infrastructure. While some
    support for some of these centers has been provided by SDFSC State
    Grants funds, in other cases support for technical assistance has been
    provided with State monies. I encourage States to continue to make this
    kind of activity a priority.
                                     ______

                Questions Submitted by Senator Mary L. Landrieu
                                   even start
        Question. The President's budget request does not include funding
    for Even Start, the national early childhood and parenting program. I
    understand that some Even Start programs in the country have not been
    effective. However, in my State of Louisiana, we have some excellent
    Even Start programs that will be devastated by this loss. Could you
    explain the decision to eliminate Even Start and propose options for
    the 60,000 participants who will be left without services?
        Answer. Based on the results of three national evaluations, the
    administration believes that the Even Start program has not yielded
    meaningful benefits for children and families. For example, the most
    recent evaluation concluded that, while Even Start participants
    demonstrated small improvements in some outcomes, they did not perform
    better than the comparison group that did not receive Even Start
    services. As a result, the administration chose to direct the resources
    to other efforts that would better address the needs of children and
    families. Specifically, the administration has requested almost $1
    billion for early childhood programs at the Department of Education,
    including $500 million for the new Title I Early Childhood Grants, $300
    million for the new Early Learning Challenge Fund, and $162.5 million
    for Early Reading First, in addition to more than $6.5 billion in
    funding for Head Start at the Department of Health and Human Services
    (HHS). Further, the Department has requested more than $628 million for
    Adult Basic and Literacy Education State Grants, a program that
    supports activities similar to some of the components of Even Start,
    such as English literacy, adult basic education, and family literacy
    services. We believe that these programs will serve the same types of
    children and adults as are served by Even Start.
                         early learning challenge fund
        Question. Your budget request includes $300 million to launch the
    Early Learning Challenge Fund. How will this fund be administered and
    how does it fit into the administration's overall vision for early
    childhood education?
        Answer. The Department will be working closely with HHS to
    administer the new Early Learning Challenge Fund program. This new
    program would support statewide systems of early learning and support
    that apply a standard set of expectations in both the educational and
    the social-emotional domains in order to provide children with the
    preparation they need to enter kindergarten ready for success while
    empowering parents to seek and select the care that best serves their
    children. The administration's overall vision is for children to come
    to school socially and cognitively prepared to learn, and we expect
    that the quality improvement efforts supported by the Early Learning
    Challenge Fund would build a pathway to improvements in early learning
    program quality and, in future years, increased investment in high-
    quality early childhood services.
                          teacher incentive fund (tif)
        Question. The administration requests the TIF increase to $517
    million. How does the administration plan to encourage these States and
    local educational agencies (LEAs) to develop and use innovative and
    effective teacher compensation systems?
        Answer. With the requested fiscal year 2010 funds, the Department
    will hold a grant competition for up to 100 new awards to LEAs,
    including charter schools that are LEAs, or States (or partnerships of:
    an LEA, a State, or both; and at least one nonprofit organization) to
    develop and implement performance-based compensation systems for
    teachers, principals, and other personnel in high-need schools.
        In an fiscal year 2010 competition, the Department will place a
    priority on the support of comprehensive, aligned approaches that: (1)
    support improved teacher and principal effectiveness and help ensure an
    equitable distribution of effective educators; (2) actively involve
    teachers (including special education teachers) and principals in the
    design of human capital and compensation systems; and (3) use data from
    emerging State and local longitudinal data systems to track outcomes
    and associate those outcomes with educator performance.
    priorities in use of funds from american recovery and reinvestment act
                     (arra) and the teacher incentive fund
        Question. How will the TIF work in conjunction with funds from the
    ARRA?
        Answer. The Department expects to use approximately $140 million of
    the ARRA appropriation for about 60 new awards, $50 million for
    continuation awards, and up to $10 million for the mandated national
    evaluation. With ARRA funds, and in response to lessons learned from
    the first two rounds of TIF grants and from other efforts around the
    country to improve educator effectiveness, the Department will place a
    priority on the support of: comprehensive, aligned approaches that
    support improved teacher and principal effectiveness and help ensure an
    equitable distribution of effective educators; that actively involve
    teachers (including special education teachers) and principals in the
    design of human capital and compensation systems; and that use data
    from emerging State and local longitudinal data systems to track
    outcomes and associate those outcomes with educator performance.
        With the funds requested for TIF in fiscal year 2010, the
    Department would launch a grant competition--for up to 100 new awards--
    encompassing the new strategies and emphases being implemented with the
    ARRA funding. This new competition will support the ARRA objectives of
    improving teacher effectiveness, reducing disparities in the access of
    students to effective teachers, and turning around persistently low-
    performing schools. Funds requested for fiscal year 2010 would also
    support 94 continuation awards.
        Priorities for an fiscal year 2010 competition would be similar to
    those for the ARRA competition; however, the Department has requested
    appropriations language that would also allow fiscal year 2010 grantees
    to use TIF funds to reward all staff in a school, as opposed to only
    teachers and principals.
                 federal facilities funding for charter schools
        Question. I was pleased to see that your budget request follows on
    President Obama's promise to increase support for charter schools. Your
    request includes a $52 million increase for Charter Schools Grants. How
    does the administration plan to address the challenges charter schools
    face in securing facilities funding?
        Answer. The administration understands that access to public
    facilities or funding for facilities is one of the major challenges
    confronting charter school operators, and we are committed to helping
    charter schools secure facilities funding. This issue will certainly be
    one that we plan to address during reauthorization. In the meantime,
    there are a number of Federal programs that support facilities
    financing for charter schools, including the State Charter School
    Facilities Incentive Grants, Credit Enhancement for Charter School
    Facilities, Qualified Zone Academy Bonds (QZABs), Qualified School
    Construction Bonds (QSCBs), Build America Bonds (BABs), and one-time
    funding under the State Fiscal Stabilization Fund (SFSF).
        The primary Federal funding sources for charter school facilities
    are the Department's State Charter School Facilities Incentive Grants
    and Credit Enhancement for Charter School Facilities programs. The
    State Charter School Facilities Incentive program provides 5-year
    grants to States with per-pupil facilities aid programs to assist
    charter schools in the purchase or acquisition of facilities. In the
    past 5 years, the Department has awarded more than $90 million to 4
    States that, by combining Federal grant funds with State matching
    funds, have provided facilities funding to more than 600 charter
    schools. The administration is committed to maintaining the momentum of
    this program and plans to award more than $12.7 million this summer to
    a new cohort of State Facilities Incentive grantees. Similarly, the
    Department's Credit Enhancement for Charter School Facilities program
    provides grants to support charter schools in the acquisition or
    renovation of facilities. The Credit Enhancement grants are awarded on
    a competitive basis to public and nonprofit entities to assist charter
    schools in securing facilities financing, through loan guarantees,
    lease guarantees, and other credit enhancement methods. These grants
    operate until the Federal funds and earnings on those funds have been
    expended for the grant purposes or until financing facilitated by the
    grant has been retired. Since 2001, the Department has awarded more
    than $214 million in grants, with another $8.3 million requested in
    fiscal year 2010, to provide charter schools with access to financing
    to help them acquire, build, or renovate school facilities.
        Charter schools may also benefit from other Federal subsidies for
    public school improvement and modernization activities, including
    QZABs, QSCBs, and BABs. The ARRA authorized tax-credit bonds for school
    construction by expanding QZABs from $400 million annually to $1.4
    billion for each of calendar years 2009 and 2010, and authorizing $11.2
    billion in the new QSCBs for each of those 2 years. QZABs provide
    funding for school repairs and renovation and certain other activities
    for eligible schools and may not be used for new construction, while
    QSCBs and BABs provide funding for new construction as well as
    renovation.
               use of sfsf for charter school facilities funding
        The SFSF, a one-time appropriation of $53.6 billion under ARRA,
    provides funds to States that also may be used to assist charter
    schools with their facilities challenges. By the end of 2009, the
    Department plans to award approximately $48.6 billion to governors
    under the SFSF program in exchange for a commitment to support
    essential education reforms, including reforms involving charter
    schools. Under the SFSF program, governors are required to use 81.8
    percent of the SFSF State grant funds to support public elementary,
    secondary, and higher education programs and 18.2 percent for public
    safety and other government services, including the modernization,
    renovation, or repair of public schools and facilities. Therefore, a
    charter school LEA should receive stabilization funding on the same
    basis as other LEAs in the State. State educational agencies (SEAs) are
    also required to take necessary steps to ensure that a newly opened or
    expanded charter school LEA receives all of the Federal formula funds
    to which it is entitled. These additional funds should help address the
    challenges many charter schools face in securing facilities funding.
          expansion and replication of promising charter school models
        Question. Currently, the Charter Schools Program funds can only go
    to new school creation and schools cannot receive more than one grant
    because of a statutory limitation. President Obama has called for
    replicating and expanding our most successful charter schools. What are
    ways in which the administration proposes to achieve this goal?
        Answer. The replication and expansion of high-quality charter
    schools will play a central role in the administration's education
    reform agenda. Since 1995, the Charter School Program (CSP) has
    provided more than $2.2 billion in financial assistance to SEAs to
    support planning, development, and initial implementation activities
    for approximately 1,200 charter schools per year, as well as fund
    dissemination activities by schools with a demonstrated history of
    success. Under the program, SEAs also may reserve up to 10 percent of
    their grant for dissemination sub-grants to share lessons learned about
    how to create, sustain, replicate, and expand high-quality, accountable
    charter schools.
        In the President's fiscal year 2010 budget request, the
    administration has proposed new appropriations language and the use of
    available waiver authority to help expand or replicate successful
    charter school models or networks. The proposed appropriations language
    would allow the Department to make direct grants to Charter Management
    Organizations or other entities for replication and expansion of
    effective charter school models, which should significantly expand the
    reach of the program. The administration also plans to strengthen
    program capacity by waiving, in appropriate circumstances, the one-
    grant limitation and the 18-month planning limitation to allow grantees
    additional time within the 36-month grant period for planning and
    implementation.
        The administration intends to use a portion of the $8 million
    available under the CSP national activities set-aside to support
    activities that promote the expansion and replication of promising
    charter school models. In fiscal year 2010, the Department plans to
    hold a new National Charter School Leadership grant competition to
    support projects of national significance that are designed to build
    State capacity and assist in the expansion of high-quality charter
    schools. The Department also will launch a new National Charter School
    Resource Center, which will provide technical assistance and resources
    to State and national charter stakeholders to expand the number of
    high-quality charter schools and increase the national understanding of
    the charter school model as a key reform strategy.
        The administration is also calling on States to reform their
    charter laws and lift caps that limit growth among excellent high-
    quality charter schools. We plan to structure the Race to the Top
    competition in such a way as to create a financial incentive for States
    to lift their charter school caps and promote accountability and high
    academic standards in all charter schools. This, in turn, would allow
    for more rapid expansion and replication of successful charter school
    models nationwide.
                              arra innovation fund
        Question. In the Innovation Fund section of ARRA, Congress included
    a special rule allowing nonprofits to apply for grants in partnership
    with LEAs. This rule says that the eligibility will be determined based
    on the track record of the nonprofit in improving student achievement.
    The intent of this language was to ensure that high-quality nonprofits
    like the ones leading reform efforts in Louisiana could compete for
    funding to grow their programs. What kind of guidance will the
    Department issue to facilitate the application process for nonprofits?
        Answer. I can assure you that we are focused on providing funds to
    LEA and nonprofits that have demonstrated results to expand their work
    and serve as models for others. The Department is working on proposed
    requirements for the Innovation Fund, which we will release shortly for
    public comment.
        Question. How will nonprofits have to show their impact on student
    achievement?
        Answer. We are working on establishing the parameters of the
    competition now and will publish the Notice of Proposed Priorities
    later this summer. The notice will include more detail on how we intend
    to run the competition, including how nonprofits can demonstrate the
    impact they have had on student achievement. We encourage the public to
    review and comment on the Notice.
                                     ______

                   Questions Submitted by Senator Mark Pryor
                   safe and drug-free schools and communities
        Question. Some concerns were raised during the hearing regarding
    the State grant and mentoring grant programs under the Safe and Drug-
    Free Schools and Communities (SDFSC) program. Can you direct me to the
    studies which determined that the State grant and mentoring grant
    programs under the SDFSC program are ineffective or not as effective as
    they were envisioned?
        Answer. For the mentoring program, the study I referred to is the
    Institute of Education Sciences (IES) ``Impact Evaluation of the U.S.
    Department of Education's Student Mentoring Program,'' which IES
    released in March 2009.
        For the Safe and Drug-Free Schools and Communities State Grant
    program, there are two studies: (1) ``Options for Restructuring the
    Safe and Drug-Free Schools and Communities Act,'' which was released by
    the RAND Corporation in 2001; and (2) ``Prevalence and Implementation
    Fidelity of Research-Based Prevention Programs in Public Schools, which
    was conducted by Westat and covered the 2004-2005 schools year.
       measuring the effectiveness of the sdfsc state grant program and
                               mentoring program
        Question. What standards did the Department of Education use when
    measuring the effectiveness of these grant programs?
        Answer. The answer follows separately for each study.
    Impact Evaluation of the U.S. Department of Education's Student
            Mentoring Program
        The mentoring program evaluation used an experimental design where
    students were randomly assigned either to receive or not to receive
    school-based mentoring from one of the Department's grantees. The
    evaluation assessed the effectiveness of the program by estimating
    impacts at the end of one school year on the intended program outcomes,
    as stated in the authorizing legislation, for students who were offered
    program services versus those who were not.
        Outcomes were collected through administration of a student survey
    and collection of student schools records, and included measures of
    ``prosocial'' behavior, absenteeism, school engagement, reading and
    math scores on State assessments, grades, future orientation, and
    delinquency (including gang membership). Promiscuous behavior was the
    only intended program outcome listed in the legislation that was not
    measured because in the initial phases of instrument development the
    study team found that questions regarding sexual behaviors or attitudes
    were not acceptable to principals or parents.
        Outcomes were measured at the end of one school year because this
    provided the most policy-relevant information. Prior research has found
    that about half of the students in school-based mentoring programs do
    not receive mentoring after the first school year and that any benefits
    from a single year of school-based mentoring do not persist beyond the
    end of the school year.
        The evaluation found that for the full sample of students, the
    program did not lead to statistically significant impacts on any of the
    measures. The full report and an executive summary are available online
    at: http://ies.ed.gov/ncee/pubs/20094047/
    Options for Restructuring the SDFSC Act
        To help inform deliberations on the SDFSC Act reauthorization in
    2001, the Department awarded a grant to the RAND Corporation's Drug
    Policy Research Center to conduct an examination of the program and
    assess options for improving it. Under the scope of the resulting
    study, RAND commissioned three analyses of school drug and violence
    prevention and prepared a background paper describing the history and
    development of the SDFSC Act program. RAND also conducted two focus
    groups with teachers and practitioners on the drug and violence
    problems in their schools and on their experiences with the program in
    their districts. These activities were preparatory to a 2-day
    conference held in July 1999, which was attended by programmatic and
    policy leadership from the Department, classroom teachers, and local
    program operators, high-level representatives with drug and violence
    prevention responsibilities in the Departments of Justice and Health
    and Human Services, and prominent researchers and policy analysts.
        The entire study is summarized in one report, and the commissioned
    papers, a summary of the focus groups, and the background paper are
    contained in a companion volume. Each can be found on-line at:

            http://www.rand.org/pubs/monograph--reports/MR1328/

                                      and

            http://www.rand.org/pubs/monograph--reports/MR1328.1/

        As the Department's fiscal year 2010 budget justification for the
    SDFSC State Grant program indicates, the study found that the program
    does not adequately target schools most needing help and generally
    spreads funding too thinly at the local level to support quality
    interventions.
    Prevalence and Implementation Fidelity of Research-based Prevention
            Programs in Public Schools
        This study examined, for the 2004-2005 school year: (1) the
    prevalence of research-based drug and violence prevention programs in
    schools; and (2) the extent to which research-based drug and violence
    prevention programs implemented in schools adhered to the program
    features on which they are based (i.e., were implemented with fidelity
    to the program design that was validated as effective by the research).
        In conducting this study more than 300 programs were screened and
    reviewed by Westat to determine the level of research rigor behind the
    programs' literature base. The study identified 21 school-based
    prevention programs that demonstrated evidence of effectiveness through
    this systematic review of literature.
        The study then used national probability sample surveys of
    districts and schools to estimate program prevalence, and national
    probability sample surveys of schools and research-based prevention
    programs to estimate fidelity of implementation. The surveys used both
    mail- and Web-based approaches to gather information on prevention
    programs and on the factors that may be associated with the adoption of
    research-based programs. Univariate analyses (e.g., percentage of
    schools with a research-based program) and bivariate analyses (e.g.,
    percentage of schools with a research-based program by the number of
    students enrolled) were conducted. Tests of statistical significance
    were conducted. Because the surveys undertaken had a complex multistage
    sample design, a replication methodology was used to establish variance
    strata and primary sampling units, and create replicate weights for
    each specific subsample of the full sample.
        The two main findings of the study were as follows: (1) only 7.8
    percent of drug and violence prevention programs and practices
    supported with SDFSC State Grant funds in 2004-05 were research-based
    (i.e., the 21 research-based prevention programs comprised only 7.8
    percent of all prevention programs implemented in schools); and (2)
    44.3 percent of SDFSC-funded researched drug and violence prevention
    curriculum programs were implemented with fidelity (i.e., met minimum
    standards for overall fidelity of implementation). The report of the
    study is expected to be completed later this year.
          safe and drug-free schools and communities national programs
        Question. How will you alter the SDFSC national program to meet the
    needs of the individual populations that are currently served through
    the State and mentoring grant programs?
        Answer. No alteration of the national programs is needed.
    Generally, under the various national programs grant competitions,
    applicants have the opportunity to select target populations and design
    and implement projects based on locally identified needs, existing
    programming, or other unique local conditions.
        Please also know that for the mentoring program, at our national
    conference in August we will be having a special grantee meeting
    focused on sustainability, to assist grantees in their transitions to
    no funding next year. We are also having discussions with
    organizations, such as Big Brothers, Big Sisters, which are active in
    mentoring, about possible assistance to grantees once the Federal
    funding ends.
                           mentoring resource center
        Finally, SDFSC mentoring program funds will support the operation
    of the Mentoring Resource Center (MRC) through the end of this fiscal
    year. The MRC has served as the Department's training and technical
    assistance provider to grantees and provided them with training,
    publications, site visits, online learning, and other opportunities for
    program and staff development. When the MRC contract ends in October we
    are considering maintaining the significant body of resources it has
    developed on an archival site, or transferring the assets to another
    Federal agency where they can be a continued resource for mentoring
    grantees and for others involved in creating mentoring programs.
                      updated guidance on title i waivers
        Question. With regard to stimulus funding, are there plans for
    additional or updated guidance pertaining to title I waivers, and if
    so, when do you anticipate this guidance to be available?
        Answer. The Department expects to release guidance on title I
    waivers related to funding provided under the Recovery Act in July
    2009.
                         students and the loan process
        Question. The fiscal year 2010 budget proposes to eliminate the
    Federal Family Education Loan Program (FFELP) and make certain that all
    Federal student loans are handled through the Direct Loan Program (DLP)
    by July 2010. One concern regarding this proposal is the potential loss
    of local services currently provided to students including loan default
    prevention, financial counseling and discounting interest rates for
    students that choose to enter high demand fields. Students can walk
    into their local bank or our State lending agency and receive personal
    guidance on making wise financial choices for their future.
        How will students navigate the student loan process if they are
    calling the Department of Education (DOE) rather than their local bank
    or lending agency?
        Answer. Students and families will see very little difference in
    the student loan process under the President's proposal. Consistent
    with current practice, initial interactions for most students will be
    with their school's financial aid office. Under either FFELP or direct
    loans, the loan process is highly automated, with applications,
    entrance and exit counseling, and other information available
    electronically through the school Website. Extensive guidance for
    students and parents is also available from the Department.
        In addition, relatively few students interact with their local bank
    for a student loan. The FFELP is highly concentrated among large
    national lenders; the 25 largest lenders account for more than 80
    percent of total volume. Local lenders that do participate in the
    program typically sell the loans before a borrower enters repayment.
    Loan servicing--which involves interactions with borrowers after they
    have left school--is even more concentrated among a small number of
    companies. Since the most efficient of these companies will be retained
    by the Department to service direct loans, with loan volume awarded
    based on performance, borrower service should be as good or better than
    that available in FFELP. The Department already provides loan default
    prevention and financial counseling services for DLP borrowers; these
    services will be expanded as the program grows.
                   role of local student loan infrastructure
        Question. Do you intend for this proposal to utilize the existing
    local infrastructure and experienced workforce currently in place or
    will the proposal rely on the larger student lending institutions?
        Answer. The President recognizes that local student loan agencies
    provide many valuable services to students and parents, and has
    specifically included those activities among those that could be funded
    under the proposed $2.5 billion College Access and Completion Fund.
    More broadly, the Department has not made a final decision regarding
    loan servicing arrangements; a procurement was just completed, however,
    that does include the requirement that the selected vendors be able to
    service all title IV federally held loans, including direct loans.
    Allocations of types and volume to any one vendor will be determined
    based upon servicer capabilities and performance. The current
    contractors have committed to sufficient capacity for the expansion of
    direct lending, and we expect they will consider subcontracting with
    other current participants in FFELP in order to more efficiently meet
    their commitments.
                  technical assistance for rural institutions
        Question. How will the Department provide assistance and training
    to 2-year colleges and technical schools in remote areas such as Black
    River Technical College in Pocahontas, Arkansas, or Phillips County
    Community College in Helena, Arkansas?
        Answer. Schools have recently transitioned to direct lending with
    little or no problem. To ensure that all schools are prepared, however,
    the Department has created a Direct Loan Transition Team to assist
    schools such as those you mention that may have unique requirements or
    need additional support. Department staff is working with those schools
    to answer questions and to offer assistance. Initial efforts have
    focused on HBCUs, HSIs, and Tribally Controlled institutions. Direct
    loan webinars have been held for community colleges and independent
    private colleges.
        The transition to direct loans should be seamless for schools of
    all sizes. The Department system that originates direct loans is called
    the Common Origination and Disbursement (COD), the same system that
    schools use to originate title IV grants (Pell Grant, ACG, National
    SMART, and TEACH). Most schools (and their computer systems) already
    interact with the system they will use for direct loans.
                  estimated savings from shift to direct loans
        Question. The Department expects to save $4 billion a year by
    switching from FFELP to DLP. What factors were used to calculate the
    estimated savings?
        Answer. Direct Loans produce savings primarily because, under
    current interest rate assumptions, borrower repayments exceed other
    program costs, including the cost of Government borrowing to finance
    loans. This results in net revenues to the Government.
                     increased federal administrative costs
        Question. Does the $4 billion include anticipated increases in
    administrative costs for the Federal Government to increase loan volume
    or for the costs associated with contracting out student lending
    services?
        Answer. Consistent with the requirements of the Federal Credit
    Reform Act, the projected savings do not include Federal administrative
    costs. Even with the addition of these costs, however, the President's
    proposal to shift to 100 percent Direct Loans produces substantial
    savings.
                     steps to increase direct loan capacity
        Question. Transitioning the student loan volume of DLP from around
    30 percent of all Federal student lending to 100 percent is a
    considerable change, and the DOE has been preparing to increase DLP
    volume. Can you explain what steps the Department is taking to prepare
    for a potential increase in DLP loan volume?
        Answer. The Department is expanding capacity for both loan
    origination and loan servicing. For loan origination, Direct Loans uses
    the COD system, which also disburses funds for the Pell Grant program,
    making the proposed expansion relatively simple for both the Department
    and participating schools. The Department has also increased its call
    center capacity to handle additional. On loan servicing, the Department
    has recently completed a procurement to substantially increase its loan
    servicing capacity. Loan volume will be allocated among the new vendors
    based on servicer capabilities and performance.
                        replacement of ffelp loan volume
        Question. Currently, the FFELP provides Federal funds to private
    lending institutions to keep interest rates on FFELP loans low and to
    reduce risks associated with providing loans to students with little or
    no credit history. Can you provide the amount of total loan volume that
    this Federal investment leverages through FFELP?
        Answer. In fiscal year 2009, the Department estimates the FFELP
    would provide $64 billion in new student loans, as well as an
    additional $1 billion in consolidations of existing loans.
                              direct loan capacity
        Question. Can the Department replicate this total loan volume in
    addition to the current volume of loans provided through the DLP solely
    through DLP?
        Answer. Yes, the Department will have the capacity to originate and
    service 100 percent of new loan volume for the 2010-2011 award year.
                              student loan volume
        Question. If the President's proposal were adopted, what level of
    total loan volume do you expect to be able to fund through the DLP in
    fiscal year 2010?
        Answer. Under current estimates, the Department would award $53.4
    billion in new loans in fiscal year 2010. Because the FFELP would
    continue to originate loans until July 1, 2010, an additional $38.3
    billion would be awarded through FFELP in fiscal year 2010, for total
    new loan volume of $91.7 billion. In fiscal year 2011, the first fiscal
    year in which direct loans would award 100 percent of new loan volume,
    total awards are estimated at $96.7 billion.
                                     ______

                 Questions Submitted by Senator Lamar Alexander
                             teacher incentive fund
        Question. I am very encouraged by the administration's proposal to
    increase the Teacher Incentive Fund to $487.3 million this year, and I
    strongly support your request. While Congress works on the
    reauthorization of the Elementary and Secondary Education Act,
    including the Teacher Incentive Fund, do you plan on making any changes
    to the program administratively?
        Answer. The Department is requesting the inclusion of
    appropriations language permitting support for approaches that provide
    performance-based compensation to all staff in a school, because
    research indicates that this type of strategy can be effective in
    raising performance across a variety of organizations. This proposed
    language would replace language permitting the funding of performance-
    based compensation only for teachers and principals.
        The Department would hold a new competition with the requested
    fiscal year 2010 funds, in addition to an upcoming Recovery Act
    competition. In both of these grant competitions, the Department will
    place a priority on the support of comprehensive, aligned approaches
    that: (1) support improved teacher and principal effectiveness and help
    ensure an equitable distribution of effective educators; (2) actively
    involve teachers (including special education teachers) and principals
    in the design of human capital and compensation systems; and (3) use
    data from emerging State and local longitudinal data systems to track
    outcomes and associate those outcomes with educator performance.
                             charter school program
        Question. I am very encouraged by the administration's proposal for
    a $52 million increase to the Charter School Program (CSP) for a total
    of $268 million this year, and I strongly support your request. I would
    have liked to see more funds reserved for charter school facilities,
    and hope that we can work to find resources for that purpose in the
    future.
        While Congress works on the reauthorization of the Elementary and
    Secondary Education Act, including the CSP, do you plan on making any
    changes to the program administratively?
        Answer. The administration is committed to supporting successful
    models of school reform, including high-quality charter schools. As you
    noted, the President's fiscal year 2010 budget has proposed an increase
    of $52 million for the CSP. We view this request as the first step in
    our effort to double support for charter schools over the next 4 years
    and to help drive reform strategies and innovation in our schools. The
    administration has proposed new appropriations language and the use of
    available waiver authority to help expand or replicate successful
    charter school models or networks. The proposed appropriations language
    would allow the Department to make direct grants to Charter Management
    Organizations or other entities for the replication and expansion of
    effective charter school models, which should significantly expand the
    reach of the program. The administration also plans to strengthen
    program capacity by waiving, in appropriate circumstances, the one-
    grant limitation and the 18-month planning limitation to allow grantees
    additional time within the 36-month grant period for planning and
    implementation.
        presidential and congressional academies for history and civics
        Question. I was very disappointed to see that the Presidential and
    Congressional Academies for History and Civics are proposed for
    elimination. I gave my maiden speech in the Senate about the importance
    of putting the teaching and learning of U.S. history back in our
    classrooms, which resulted in the creation of these academies, with the
    support of Senator Reid, Senator Byrd, and Senator Kennedy. While it is
    a small program, teachers and students each summer have benefited
    greatly which is why I recently introduced legislation to expand the
    program and why I hope that the Appropriations Committee will continue
    to fund these programs.
        What can I do over the course of the next year to convince you of
    the merit of the Presidential and Congressional Academies?
        Answer. The teaching of history in our classrooms is important to
    the administration and will continue to receive significant Federal
    funding. We proposed to eliminate the Presidential and Congressional
    Academies for History and Civics because we feel the program is too
    small to have a substantial national impact. Furthermore, the level of
    effort required to administer and monitor the program on behalf of the
    Department, in addition to the effort required of applicants to apply
    for support, provides compelling reasons to put resources into larger
    programs with a greater chance of having a national impact. Instead of
    the academies, we are proposing the creation of a competitive grant
    program of more significant size called ``History, Civics, and
    Government'' that will ``scale-up'' effective practices and encourage
    wider adoption of successful programs in these subject areas. In
    addition to the new initiative, the administration continues to support
    the Teaching American History and Teacher Quality State Grants
    programs, which make substantial funding available for the professional
    development of history teachers nationwide.
        The Department is looking closely at the effectiveness of all our
    programs, and in the coming years will make a greater and greater
    effort to request funding only for programs that can demonstrate
    evidence of effectiveness. If we are able to determine that the
    Presidential and Congressional Academies program had clear evidence of
    effectiveness (for instance, that the teachers who participate in the
    Presidential academies were raising the level of student achievement in
    their classrooms, or that the high school students attending the
    congressional academies were receiving a clear benefit that was somehow
    being extended to a wider population of students), we would likely look
    at the program differently. This evidence would need to be more than
    past survey results showing that the teachers and students enjoyed
    participating and liked the programs, which is frequently the type of
    ``evaluations'' that teacher in-service training and similar programs
    produce.
                            choice in student loans
        Question. I have repeatedly expressed my concerns about the
    administration's proposal to convert the entire student loan program
    into the Government-run Direct Loan program. The Senate has agreed that
    parents, students, and schools should be able to make their own choices
    of student loan providers, as the current programs allow.
        How does your proposal seek to retain the power of the competitive
    marketplace where parents, students, and schools can choose the best
    providers to help them afford their college tuition?
        Answer. The competitive marketplace will play a key role in the
    Department's plans to ensure that students, parents, and schools
    continue to receive high-quality service. We have already contracted
    with a number of private-sector firms with extensive experience in the
    Federal Family Education Loan Program (FFEL) to expand our loan
    servicing capabilities. Work will be allocated among these vendors
    based on their performance; customer satisfaction will be among the key
    criteria used in determining these allocations. Private-sector vendors,
    chosen through competitive procurements, will also provide default
    aversion and collection services and borrower counseling.
     administrative cost of originating all federal student loans through
                              direct loan program
        Question. I am also concerned about the estimated costs of
    administering this new program. The administration budget only asks for
    an increase of $117 million from $753 million to take over the FFEL
    Program. Could you provide the Appropriations Committee with estimates
    of what those total annual discretionary costs would be for the next 5
    years to originate and administer all loans under the Direct Loan
    program?
        Answer. Estimated costs for Student Aid Administration depend on
    many factors, most significantly origination and servicing volume.
    Recently, this volume has proven to be quite volatile, due in large
    part to loan purchase programs authorized by the Ensuring Continued
    Access to Student Loans Act of 2008. The recent introduction of
    multiple servicer contracts has also introduced a level of uncertainty.
    However, given current conditions, it is estimated that total Student
    Aid Administration costs will total approximately $5.5 billion to $6.5
    billion over the next 5 years.
                            funding for pell grants
        Question. I agree that we should not charge students more for their
    student loans in order to generate profits for lenders. That's why I
    supported the College Cost Reduction Act which reduced the Special
    Allowance Payment for lenders and generated savings for students.
        However, I am concerned about the administration's proposal to
    convert the entire student loan program into the Government-run Direct
    Loan program and use the profits made from charging students an
    artificially high interest rate on their loans to provide generous
    increases to the Pell Grant.
        According to the Congressional Budget Office, the majority of
    savings generated by the administration's proposal comes from charging
    most students on most loans 6.8 percent in interest when it costs the
    Government much less to originate and service the loan.
        Why shouldn't students be charged a lower interest rate to cover
    the actual costs of the loan instead of asking them to pay more in
    interest over the course of the life of their loan to generate revenue
    for the Federal Government to pay for the Pell Grant increases?
        Answer. The administration strongly believes Federal student aid
    resources should be focused on broadening access to higher education
    for all Americans. Particularly in today's economically challenging
    times, the need-based Pell Grant program is the best vehicle for
    helping disadvantaged students and families attend colleges and other
    postsecondary institutions.

                              SUBCOMMITTEE RECESS

        Senator Harkin. Thank you for your leadership. Thank you,
    Mr. Secretary. Well, the subcommittee will stand adjourned.
        [Whereupon, at 11:36 a.m., June 3, the subcommittee was
    recessed, to reconvene subject to the call of the Chair.]

      DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES, AND EDUCATION, AND
              RELATED AGENCIES APPROPRIATIONS FOR FISCAL YEAR 2010

                                  ----------

                             TUESDAY, JUNE 9, 2009

                                           U.S. Senate,
               Subcommittee of the Committee on Appropriations,
                                                        Washington, DC.
        The subcommittee met at 2:30 p.m., in room SD-124, Dirksen
    Senate Office Building, Hon. Tom Harkin (chairman) presiding.
        Present: Senators Harkin, Kohl, Pryor, Specter, Cochran,
    and Alexander.

                    DEPARTMENT OF HEALTH AND HUMAN SERVICES

                            Office of the Secretary

    STATEMENT OF HON. KATHLEEN SEBELIUS, SECRETARY

                    OPENING STATEMENT OF SENATOR TOM HARKIN

        Senator Harkin. The Subcommittee on Labor, Health and Human
    Services, Education, and related agencies will come to order.
        Madam Secretary, I welcome you to your first hearing with
    this Appropriations subcommittee. You have a challenging job
    ahead of you, I believe the most challenging job, I think, in
    the Cabinet, but also I think the best job in the Cabinet.
        Your responsibilities include not only comprehensive
    healthcare reform, preparing for a possible pandemic influenza,
    addressing costs of entitlements, but also biomedical research,
    substance abuse, drug safety, and quite a few others.
        I certainly look forward to working with you in any way
    that I can. This hearing will focus of your discretionary
    budget, but I would just like to mention what we're doing on
    comprehensive healthcare reform.
        I know that you feel very strongly that prevention in
    public health must be at the heart of any serious reform of the
    healthcare system and I commend you for your work in that area.
    I also believe that any reform of the healthcare system must
    address the injustice of people with severe disabilities, who
    are being forced to spend their lives in nursing homes because
    we do not provide the option of home-based services for the
    severely disabled. That's why I've introduced the Community
    Choice Act of 2009 (S. 683), which President Obama strongly
    supported during the campaign and which he co-sponsored when he
    was here as a member of this subcommittee. So, I look forward
    to working with you on this issue.
        Today, we want to talk about the fiscal year 2010 budget
    and also about the funding included in the Recovery Act of the
    stimulus that we passed. That bill included $10 billion for the
    National Institutes of Health (NIH), $1.1 billion for
    comparative effectiveness research, $700 million for prevention
    activities and $2 billion for discretionary health information
    technology activities, as well as funds for Head Start, child
    care, Community Services Block Grant, and health professions.
        So, we will cover as much as we can. Again, we welcome you
    to the subcommittee. I will leave the record open for a
    statement by Senator Cochran and I would then recognize you,
    Madam Secretary, and your statement will be made a part of the
    record in its entirety.

               HEALTHCARE WASTE AND HOSPITAL-ACQUIRED INFECTIONS

        And, as a matter of introduction, Kathleen Sebelius became
    the 21st Secretary of the Department of Health and Human
    Services on April 29, 2009. In 2003, she was elected as
    Governor of Kansas. And I thank you for coming up to Iowa many
    times. I always enjoyed seeing you in Iowa and working with
    you. She served in that capacity until her appointment as
    Secretary.
        Prior to her election as Governor, she served as the Kansas
    State Insurance Commissioner and is a graduate of Trinity,
    Washington University, and the University of Kansas.
        Madam Secretary, Mr. Cochran.
        Senator Cochran. Mr. Chairman, I am happy to join you in
    welcoming the Secretary to the hearing. Thank you very much.
        Senator Harkin. Thank you, Senator. I left the record open
    for your statement.
        Madam Secretary, welcome. And please proceed as you so
    desire.

                  SUMMARY STATEMENT OF HON. KATHLEEN SEBELIUS

        Secretary Sebelius. Well, thank you Chairman Harkin,
    Senator Cochran, and members of the subcommittee. I want to
    thank you for the invitation to come and discuss the 2010
    budget.

                               HEALTHCARE REFORM

        I want to first start by thanking you for your hard work
    and leadership on a whole variety of health issues. We
    certainly face great challenges in the country today and I look
    forward to working with you to tackle those challenges
    together. Healthcare reform is one of the issues I know that is
    front and center in the Senate and the House right now and I
    think that there is great agreement that we can't continue with
    the status quo. The President is committed to healthcare
    reform. I think we're seeing businesses and Government and
    families and providers come together to acknowledge that the
    crushing costs are influencing family's bottom-line, the
    competitiveness of our businesses, and we have to find a way to
    deliver higher quality healthcare for all Americans.
        I do agree with you, Senator, that prevention and wellness
    are an essential component of that transformational health
    policy. And some of those building blocks, as you say, have
    already been provided. But I look forward to being part of that
    discussion as it moves forward, in terms of healthcare reform.
        Now, I think the budget we're considering today puts us on
    the path to healthcare reform and adheres to the principles
    outlined by the President, building on the investments in a
    21st century healthcare system. The American Recovery and
    Reinvestment Act funded some priority areas, including making a
    substantial down-payment on healthcare reform.
        There's a focus on fraud, which is costing taxpayers
    billions of dollars each year. And we intend to do more to
    crack down on individuals who currently cheat the system. So,
    the Attorney General and I, first time ever at a Cabinet level,
    announced an interagency effort to fight Medicare and Medicaid
    fraud through improved data sharing, real-time information that
    would be available, and increase the number of strike forces
    that have been successful in a couple of areas and we would
    like to see them increase their operations. And the budget
    includes some recommended increase to help Health and Human
    Services achieve our part of the bargain.
        We also have initiatives in the budget to move toward a
    central goal of healthcare reform, improving the quality of
    care. The patient-centered research that is funded in this
    budget helps give doctors and patients access to better
    information and better treatments, helps empower consumers and
    providers. So we hope that, not only would we be looking at
    some cost-saving strategies, but improving the quality of
    healthcare for everyone.

                             HEALTHCARE DISPARITIES

        The budget invests $354 million in target activities to
    combat health disparities. Senators, I just came from a
    dialogue with close to 30 stakeholders representing various
    minority populations and communities who are very interested in
    working on closing the gap on quality of healthcare delivered
    across America. The gap that exists for higher income Americans
    versus lower income Americans and certainly the gap that we see
    persistent in ethnic minorities and low income and
    disadvantaged populations and that is a continued priority with
    the Department.
        We have included more than $1 billion in the Health
    Resources and Services Administration (HRSA) to support a wide
    range of programs dealing with the workforce issues. Clearly a
    critical component of healthcare reform is having enough
    providers to deliver the care to all Americans. So, the funding
    will enhance the number of nurses and doctors, the number of
    dentists and mental health professionals, and particularly also
    targets minority and low-income students to encourage more
    access to the medical profession. And an increased emphasis to
    make sure seniors get the care and treatment they need.

                                  PANDEMIC FLU

        And finally, the budget will support our work at the
    Department to protect public health and the safety of our
    citizens. As the chairman has recognized, we are not only
    dealing with an ongoing presentation of the H1N1 flu virus, but
    also the ongoing preparedness and operations to respond to
    whatever outbreaks may strike next and threaten the health of
    the American people.
        There's no question that the investments made in pandemic
    planning and preparation by this subcommittee and Congress over
    the years has allowed our Department to respond efficiently,
    but we need to continue those efforts and make sure that we are
    well-prepared. We don't know what the next depths of this virus
    might be when it comes back in the fall in this country or what
    will happen exactly this summer, when it presents itself in the
    Southern Hemisphere in conjunction with their flu season. So,
    the President has submitted a supplemental request to support
    the Federal response to the recent outbreak. So the funds, in
    addition to those provided in the 2010 budget, will allow our
    Department to continue to be the primary health agency
    responding to this outbreak and remain prepared to protect the
    American people.
        So Mr. Chairman, the President is committed to a safer,
    healthier, and more prosperous America and we feel this budget
    will help achieve those goals, investing in reform, improving
    on the quality of care, and continuing to provide essential
    services that so many families depend on.

                               PREPARED STATEMENT

        So, I look forward to taking your questions and those from
    other subcommittee members and, more importantly, to work with
    you on these important goals.
        Senator Harkin. Madam Secretary, thank you very much for
    your summation and, as I said, your full statement will be made
    a part of the record in its entirety.
        [The statement follows:]
                    Prepared Statement of Kathleen Sebelius
        Chairman Harkin, Senator Cochran, and members of the subcommittee,
    thank you for the invitation to discuss the President's fiscal year
    2010 budget for the Department of Health and Human Services (HHS).
        In these times of economic uncertainty, we at HHS are even more
    cognizant of the healthcare needs of American citizens. It is during
    times like these that we must be especially mindful to answer the call
    as public servants to protect the health of the American people as well
    as ensure the availability of healthcare resources. At HHS, we are
    dedicated to the continued improvement and accessibility of healthcare
    in the United States and committed to providing essential human
    services that families depend on, particularly in times of economic
    crisis.
        The HHS fiscal year 2010 budget reflects a dedication to focus
    resources in the areas of health reform, improving the quality and
    accessibility of healthcare, delivering human services to vulnerable
    populations, securing and promoting public health, investing in
    scientific research and development, and ensuring the successful
    implementation of the American Recovery and Reinvestment Act.
        The President's fiscal year 2010 budget for HHS totals $879 billion
    in outlays. The budget proposes $78 billion in discretionary budget
    authority for fiscal year 2010, of which $72 billion is within the
    jurisdiction of the Labor, Health and Human Services, Education, and
    related agencies Subcommittee.
    Health Reform
        I would like to begin my comments by addressing our efforts in the
    area of health reform.
        One of the biggest drains on American family budgets and the
    performance of the economy is the high cost of healthcare. American
    families and small businesses are being crushed by sky-rocketing
    healthcare costs and they are losing the very choices they value most.
        Health insurance premiums have doubled since 2000, rising four
    times faster than wage growth. This increase strains both families and
    the businesses that struggle to sustain health benefits for their
    employees. At the same time, healthcare costs are consuming a rapidly
    growing share of Federal and State government budgets.
        The United States spends more than $2.2 trillion on healthcare each
    year, a number that represents about 16 percent of the total economy.
    Experts predict that by 2018, 20 percent of the economy will be spent
    on healthcare.
        Despite this record spending, about 46 million Americans lack
    healthcare coverage. The President is committed to reform that assures
    quality, affordable healthcare for all Americans. Covering all
    Americans is not only a moral imperative, but it is also essential to a
    more effective and efficient healthcare system.
        HHS has already made major strides towards this goal.
        We have supported efforts at the Centers for Medicare and Medicaid
    Services such as the Children's Health Insurance Program, which has
    provided healthcare for millions of previously uninsured children.
        The administration is using Recovery Act dollars wisely to protect
    coverage for families and help strengthen our healthcare system. The
    funds this subcommittee provided are protecting Medicaid coverage and
    improving health services to low-income Americans. The Recovery Act
    temporarily lowers the cost of COBRA coverage by 65 percent for some
    workers and their families, helping workers who lost their jobs hold
    onto the coverage they need.
        The Recovery Act advances the President's health IT initiative and
    accelerates the adoption of health information technology--an essential
    tool to modernize the healthcare system--and the utilization of
    electronic health records. We are striving to improve care and give
    patients and doctors more information by devoting $1.1 billion to
    comparative effectiveness research. In addition, we are working to
    improve the health of all Americans by investing $1 billion in
    prevention and wellness.
        These are important first steps, but there is much more work to be
    done to ensure all Americans have the high-quality, affordable coverage
    they deserve.
        Consistent with the President's vision for a reformed healthcare
    system that offers affordable, quality healthcare to all Americans, the
    HHS budget invests in key priority areas and puts us on the path to
    health reform.
        The budget sends a clear message that we can't afford to wait any
    longer if we want to get healthcare costs under control and improve our
    fiscal outlook. Investing in health reform today will help bring down
    costs tomorrow and ensure all Americans have access to the quality care
    they need and deserve.
        Consistent with these principles, the budget takes a significant
    step towards comprehensive reform and establishes a healthcare reserve
    fund of $635 billion over 10 years to finance health reform that brings
    down costs, improves quality, and assures coverage for all Americans.
    The reserve will be funded by new revenue and by savings from Medicare
    and Medicaid. While the reserve fund is a significant commitment, we
    are aware that this amount is not sufficient to fully fund
    comprehensive reform, and we look forward to working with the Congress
    to identify additional resources.
        This saving proposal is supported by the following initiatives:
        Aligning Incentives Toward Quality.--The budget includes proposals
    intended to improve incentives to provide high quality care in
    Medicare, including quality incentive payments to hospitals and
    voluntary physician groups and reduced payments to hospitals with high
    readmission rates.
        Promoting Efficiency and Accountability.--The budget includes
    savings resulting from increased efficiency and accountability in
    Medicare and Medicaid, including reducing Medicare payments to private
    insurers by encouraging competition, implementing policies to decrease
    Medicaid costs for prescription drugs, improving Medicare and Medicaid
    payment accuracy, and bundling Medicare payments for inpatient hospital
    and certain post-acute care.
        Encouraging Shared Responsibility.--The budget recognizes that
    successfully moving toward a reformed healthcare system will require
    all stakeholders to contribute a proportionate share. The budget
    includes a proposal to require certain higher-income Medicare
    beneficiaries enrolled in Part D to pay higher premiums, as is
    currently required for physician and outpatient services.
        New Revenues.--Among other changes, the budget includes a proposal
    to limit the rate at which high-income taxpayers can take itemized
    deductions against revenues dedicated to health reform. This will help
    provide the savings needed to fund comprehensive health reform.
    Improving Quality and Access to Health Care
        At HHS, we continue to strive to find ways to better serve the
    American public, especially those citizens less able to help
    themselves. We are working to improve the quality of and access to
    healthcare for all Americans by supporting programs intended to enhance
    the healthcare workforce as well as the quality of health care
    information and treatments through the advancement of health
    information technology (IT) and the modernization of the healthcare
    system.
        The budget includes more than $1 billion within the Health
    Resources and Services Administration (HRSA) to support a wide range of
    programs to strengthen and support our Nation's healthcare workforce.
    This funding will enhance the capacity of nursing schools, increase
    access to oral healthcare through dental workforce development grants,
    target minority and low-income students, and place an increased
    emphasis on ensuring that America's senior population gets the care and
    treatment it needs.
        The budget also supports HHS-wide comparative effectiveness
    research, including $50 million within the Agency for Healthcare
    Research and Quality. This research will improve healthcare quality by
    providing patients and physicians with state-of-the-science information
    about which medical treatments work best for a given clinical
    condition.
        The budget advances the President's health IT initiative and
    accelerates the adoption of health information technology--an essential
    tool to modernize the healthcare system--and the utilization of
    electronic health records (EHR). The Office of the National Coordinator
    for Health Information Technology will continue its current efforts as
    the Federal health IT leader and coordinator. During fiscal year 2010,
    HHS will prepare to provide Recovery Act Medicare and Medicaid
    incentive payments to physicians and hospitals who demonstrate
    meaningful use of certified EHRs.
        The Centers for Medicare and Medicaid Services (CMS) Program
    Management account increases by $235 million in fiscal year 2010 to
    cover statutory and policy workloads in claims processing and in
    healthcare facility survey frequencies to adequately protect
    beneficiary quality of care and safety. CMS Program Management funding
    increases will also go to important initiatives such as ICD-10
    implementation and additional funding for Medicare Improvements for
    Patients and Providers Act of 2008 (MIPPA) implementation as well as
    the necessary increase in staff to administer new workloads from MIPPA
    and other recent legislation. CMS will also expand its research efforts
    to lay the groundwork for long-term reforms of CMS' programs and the
    Nation's healthcare system.
    Delivering Human Services to Vulnerable Populations
        HHS shares the President's belief in increasing access to critical
    services and healthcare for citizens most in need of assistance. HHS
    takes seriously our responsibility to reach out to those Americans
    least able to provide for themselves such as children and senior
    citizens as well as those in rural areas where quality, affordable
    healthcare and services are less accessible.
        Due chiefly to Recovery Act funding, the Head Start program run by
    the Administration for Children and Families (ACF), will serve 978,000
    children in fiscal year 2009, an increase of approximately 70,000 over
    fiscal year 2008. Approximately 115,000 infants and toddlers, nearly
    twice as many as in fiscal year 2008, will have access to Early Head
    Start services in fiscal year 2009 and fiscal year 2010. The budget
    includes an additional $122 million to enable Head Start to sustain the
    historic increase in children served.
        The budget includes $178 million in funds to support evidence-based
    teen pregnancy prevention programs. To improve outcomes for women and
    children, the President's budget also assumes $124 million for a new
    mandatory Home Visitation program to establish and expand home
    visitation programs for low-income families.
        The budget includes $3.2 billion for the ACF Low Income Home Energy
    Assistance Program (LIHEAP), one of the largest LIHEAP funding requests
    ever. Energy prices are volatile, making it difficult to match funding
    to the needs of low income families. For this reason, the budget
    includes a legislative proposal to provide additional mandatory LIHEAP
    funding if energy prices increase significantly.
        The budget includes $59 million, an increase of $35 million, within
    the Substance Abuse and Mental Health Services Administration to expand
    the treatment capacity of drug courts. Within this increased funding
    for drug courts, $5 million will support families affected by
    methamphetamine abuse. The budget also includes $986 million, an
    increase of $17 million, for the prevention and treatment of mental
    illnesses.
    Securing and Promoting Public Health
        Whether it's responding to the H1N1 flu virus or the recent recall
    of peanuts, HHS is responsible for keeping Americans healthy and safe,
    and we take that responsibility seriously.
        The budget will help ensure we remain prepared to protect the
    American people. The investments we made in pandemic planning and
    preparation allowed us to respond quickly and efficiently to the H1N1
    virus in this country and helped get Americans the information and
    resources they needed early on during the outbreak.
        The administration has requested supplemental funding to support
    the Federal response to the recent outbreak of 2009 H1N1 influenza.
    Resources will be vital to support the immediate response and to
    support potential longer term needs as determined by the severity of
    the virus in the Southern Hemisphere. It is important that we take
    steps now to ensure resources are available on a contingency basis in
    case they are needed. These funds, in addition to the fiscal year 2010
    budget of $584 million, will allow HHS to develop and produce vaccines
    as well as distribute antivirals, personal protective equipment, and
    other medical countermeasures. This funding will also support public
    health surveillance and response efforts in the face of the current
    outbreak.
        HHS has been working diligently to ensure that the public will be
    protected from this H1N1 virus and has created an H1N1 virus reference
    strain that has been distributed to the manufacturers to create a virus
    master seed. HHS recently committed $1.1 billion, through new orders on
    existing manufacturer contracts, to develop and test bulk supply of
    vaccine antigen and adjuvant for the production of pilot lots of an
    H1N1 vaccine. The Centers for Disease Control and Prevention (CDC),
    Office of the Assistant Secretary for Preparedness and Response, Food
    and Drug Administration, and NIH are working together to develop a
    commercial-scale vaccine production strategy, as well as working on the
    development of vaccine candidates.
        HHS has also declared a nationwide Public Health Emergency;
    deployed teams to affected States according to the CDC Incident Action
    Plan; released 25 percent, or 11 million treatment courses of the
    antivirals in the Strategic National Stockpile for distribution to
    States; issued Emergency Use Authorization of diagnostic laboratory
    tests and to treat children under the age of 1 year with Tamiflu;
    issued regularly updated guidance for healthcare providers, public
    health officials, and the public on recommendations on antivirals,
    symptoms and reducing spread of the virus; and continued surveillance
    activities, particularly in the Southern Hemisphere to monitor the H1N1
    virus.
        People living with HIV disease are, on average, poorer than the
    general population, and Ryan White HIV/AIDS Program clients are poorer
    still. For them, the Ryan White HIV/AIDS Program is the payor of last
    resort because they are uninsured or have inadequate insurance and
    cannot cover the costs of care on their own, and because no other
    source of payment for services, public or private, is available. The
    budget includes more than $3 billion in CDC and HRSA to enhance HIV/
    AIDS prevention, care, and treatment. Within HRSA, an additional $54
    million is included for the Ryan White HIV/AIDS Program to increase
    access to healthcare among uninsured and underinsured individuals
    living with HIV/AIDS and to help reduce HIV/AIDS-related health
    disparities. Within CDC, an additional $53 million is included to
    enhance testing and other HIV/AIDS prevention efforts.
        The President's request also includes $354 million for combating
    health disparities and will help improve the health of racial and
    ethnic minorities and low-income and disadvantaged populations. This
    proposal includes $143 million for the Minority AIDS Initiative under
    the Ryan White Act, $116 million for Health Professions and Nursing
    Training Diversity Programs, $56 million for the Office of Minority
    Health, and $40 million for the REACH program administered by the CDC.
        Rural Americans also often receive substandard care and the fiscal
    year 2010 budget includes $73 million for a new ``Improve Rural Health
    Care'' initiative, which increases access and improves the quality of
    care in rural areas.
    Investing in Scientific Research and Development
        HHS is dedicated to finding better ways to treat and prevent
    illnesses such as cancer through the support of programs dedicated to
    advancing medical research and development. The HHS budget includes
    nearly $31 billion for the National Institutes of Health (NIH) to
    continue support of biomedical research. These funds build on the
    unprecedented $10.4 billion in total provided to NIH in the Recovery
    Act. Within the budget total, more than $6 billion will support cancer
    research across NIH. This funding is central to the President's
    sustained plan to double NIH cancer research over 8 years. In fiscal
    year 2010, NIH estimates it will support a total of 38,042 research
    project grants, including 9,849 new and competing awards.
    Recovery Act
        The Department's portion of the American Recovery and Reinvestment
    Act of 2009 addresses and responds to critical challenges in our
    healthcare system and enhances human services through investments that
    immediately impact the lives of Americans.
        The American Recovery and Reinvestment Act includes an estimated
    $167 billion over 10 years for programs at HHS. HHS mandatory budget
    authority is increased by an estimated $144 billion, which includes
    $113 billion for Medicaid, $23 billion for Medicare, $7 billion for the
    ACF entitlement programs, and $1 billion for administration. Most of
    the increase in this funding will take place in fiscal year 2009 and
    fiscal year 2010.
        HHS also received $22 billion in discretionary budget authority.
    The majority of these funds will be obligated by September 2010 to
    achieve the most rapid impact for citizens and States affected by the
    current economic downturn.
        HHS Recovery Act activities support efforts to increase access to
    healthcare, protect those in greatest need, expand educational
    opportunities, and modernize the Nation's infrastructure. HHS is
    committed to quickly and carefully distributing Recovery Act funds in
    an open and transparent manner that will achieve the objectives of the
    Recovery Act. HHS released over $16 billion in Recovery Act funds
    within the first 30 days of enactment, including crucial fiscal relief
    to States through increased Medicaid funding, funds for health centers,
    and funds for foster care and adoption assistance. Overall, HHS will
    distribute more than 90 percent of its increased discretionary funding,
    and approximately two-thirds of its increased mandatory spending,
    within 2 years of enactment.
        Consistent with the President's call for accountability and
    responsible management in the Federal Government, HHS has established
    new policy and technical processes to review spending plans and to
    implement the Recovery Act requirements for transparency and
    accountability. To coordinate and manage the complexity of HHS' role
    and processes in the Recovery Act, HHS established an Office of
    Recovery Act Coordination run out of the Office of the Secretary. The
    Recovery Act also provides $48 million for the Office of Inspector
    General to enhance accountability and enforcement activities to prevent
    waste, fraud, and abuse.
    In Closing
        Consistent with the President's vision for a safer, healthier, and
    more prosperous America, HHS will continue to seek improvements and
    strive to exceed expectations in areas such as securing and promoting
    public health, delivering human services to vulnerable populations, and
    improving quality of and access to healthcare. HHS will continue to
    make investments that will improve the lives of children, families, and
    seniors by creating a healthy foundation for everyone to fully
    participate in the American community.
        Again, I would like to thank the subcommittee for this opportunity
    to offer my comments and I look forward to working with you to advance
    the health, safety, and well-being of the American people.

               HEALTHCARE WASTE AND HOSPITAL-ACQUIRED INFECTIONS

        Senator Harkin. Madam Secretary, thank you very much for
    your summation and, as I said, your full statement will be made
    a part of the record in its entirety. Madam Secretary, there is
    an article in The Washington Post this morning on healthcare.
    It pointed out two important things. It says here, ``The
    pockets of medical excellence dot the landscape, but at least
    100,000 people die each year from infections they acquired in
    the hospital. While 1.5 million are harmed by medication
    errors.'' And down here, ``yet The Institute of Medicine
    estimates that one-third of all medical care is pure waste such
    as duplicate X-rays, repeat lab tests, and procedures to fix
    mistakes.''
        [The information follows:]

                    [From The Washington Post, June 9, 2009]

           Decision Makers Differ on How to Mend Broken Health System
                               (By Ceci Connolly)
        Nowhere else in the world is so much money spent with such poor
    results.
        On that point there is rare unanimity among Washington decision
    makers: The U.S. health system needs a major overhaul.
        For more than a decade, researchers have documented the inequities,
    shortcomings, waste and even dangers in the hodgepodge of uncoordinated
    medical services that consume nearly one-fifth of the nation's economy.
    Exorbitant medical bills thrust too many families into bankruptcy,
    hinder the global competitiveness of U.S. companies and threaten the
    government's long-term solvency.
        But the consensus breaks down on the question of how best to create
    a coordinated, high-performing, evidence-based system that provides the
    right care at the right time to the right people.
        During eight years in office, President George W. Bush took an
    incremental approach, adding prescription drug benefits to the Medicare
    program for seniors and the disabled and expanding the number of
    community clinics nationwide. President Obama, like the last Democrat
    to occupy the White House, contends that was insufficient and is
    pushing for an ambitious reworking of the entire $2.3 trillion system.
        Framed by President Bill Clinton 16 years ago as a moral imperative
    to deliver health care to all, this summer's historic debate comes
    against a more urgent backdrop. As the national unemployment rate nears
    10 percent and giants such as General Motors crumble, the expensive,
    inefficient health system has deepened the country's economic woes.
        By virtually every measure, the situation has worsened.
        Today, about 46 million Americans have no health insurance, so they
    go without or wait in emergency rooms for expensive, belated care.
    Everyone else helps pay for that Band-Aid fix in the form of higher
    taxes and an extra $1,000 a year in insurance premiums.
        Pockets of medical excellence dot the landscape, but at least
    100,000 people die each year from infections they acquired in the
    hospital, while 1.5 million are harmed by medication errors. Of 37
    industrialized nations, the United States ranks 29th in infant
    mortality and among the world's worst on measures such as obesity,
    heart disease and preventable deaths.
        Bright young physicians trained at prestigious and expensive
    universities enter a profession built on perverse financial rewards.
    They, like assembly-line workers of the past, are paid on a piecemeal
    basis, earning more money not by doing better but simply by doing more.
        Yet more care rarely translates into better health. Extensive
    research by Dartmouth College has found the exact opposite: Health
    outcomes are often best in communities that spend less compared with
    cities such as Boston and Miami where the medical arms race of
    specialists and high-tech gadgets often leads to greater risks and
    injuries.
        The Institute of Medicine estimates that one-third of all medical
    care is pure waste, such as duplicate X-rays, repeat lab tests and
    procedures to fix mistakes.
        ``Most Americans don't understand how bad health care in the United
    States is,'' said Michael F. Cannon, head of health policy at the
    libertarian Cato Institute. ``We need big reforms.''
        Across the ideological spectrum, the diagnosis is remarkably
    consistent.
        ``Sure, some people here have the best health care in the world,
    but the average American is paying too much and not getting enough in
    return,'' said John D. Podesta, who led Obama's transition team and
    heads the Center for American Progress, a think tank.
        Said Sen. Judd Gregg (R-N.H.): ``What's tragic is that so much of
    this spending is on duplicative or unnecessary care that doesn't
    improve health outcomes.''
        Simply put, the goal of health reform is to finally get our money's
    worth, say industry leaders, policymakers, consumers and business
    executives.
        They envision a health-care system that guarantees a basic level of
    care for everyone, shifts the emphasis to wellness and prevention,
    minimizes errors, and reduces unnecessary and unproved treatment. Such
    a system would coordinate care, track patients and doctor performance
    electronically, and reward good results. The high-value system of the
    future would be organized ``so that people get the care they need and
    need the care they get,'' said Elizabeth A. McGlynn, associate director
    of the health research division of Rand Corp.
        Nowadays, that is often not the case.
        On average, Americans receive the recommended, proven care 55
    percent of the time, according to Rand studies. Sometimes, doctors or
    nurses overlook a basic but critical step, such as prescribing a beta
    blocker medication to patients after a heart attack, a therapy shown to
    significantly reduce the risk of a fatal attack. At other times,
    patients undergo procedures when there is no evidence that they are any
    better than a simpler, cheaper alternative.
        Ten years ago, in its landmark report ``To Err is Human,'' the
    Institute of Medicine estimated that 44,000 to 98,000 people die each
    year from medical mistakes, highlighting the need for improvement.
    Since then, the tally has risen, said Janet Corrigan, president of the
    National Quality Forum, a nonprofit membership organization that
    promotes quality standards.
        ``We now know estimates of those who die from hospital-acquired
    infections is upwards of 100,000,'' she said. ``Many of those, if not
    most, are avoidable and preventable.''
        Sen. Robert C. Byrd's recent hospital stay, for example, has been
    extended because the West Virginia Democrat developed a staph
    infection.
        ``Everyone agrees that hospitals are hazardous to your health,''
    said Mitchell Seltzer, a consultant who advises large medical
    institutions. ``For every day a patient is in a bed, they are subjected
    to a higher probability of medical errors, hospital-acquired
    infections, inappropriate tests that do not have a direct bearing on
    the medical condition being treated.''
        Part of the problem is cultural, said Rand's McGlynn.
        ``People tend to demand the new thing even if there's not much
    evidence it will make a difference in the length or quality of life,''
    she said.
        Few patients or physicians have any idea who delivers good, or bad,
    care, because few organizations track results. Consumers have more
    information to evaluate their cars than they do their surgeons. ``It's
    like a doctor flying the plane without instruments,'' said James N.
    Weinstein, a spine surgeon who directs the Dartmouth Institute for
    Health Policy and Clinical Practice.
        Obama set aside $19 billion in his economic stimulus package to
    promote the use of digital records, on the belief that they reduce
    duplication, produce more consistent care and cut down on errors.
        Because the fee-for-service payment system rewards quantity over
    quality, there is little incentive--and there are even disincentives--
    for doctors, nurses and hospitals to improve, Corrigan said.
        ``Is it a surprise we have lots of extra imaging tests and lab
    tests?'' she said. ``Not at all.''
        The consequences are especially glaring in regions with larger
    numbers of specialists and pricey technology, the Dartmouth data show.
        Take the case of Miami vs. La Crosse, Wis. In 2006, using
    inflation-adjusted figures, Medicare spent $5,812 on the average
    beneficiary in La Crosse, compared with $16,351 in Miami. Yet an
    examination of health status in both places, adjusted for age, finds no
    evidence that the extra spending resulted in better care, Weinstein
    said.
        ``That's the enigma here,'' he said. ``Less is more, and more isn't
    better.''
        Physician behavior and spending patterns in Medicare have been good
    indicators of broader trends across the nation, Dartmouth has found.
        Even the best physicians cannot stay current with all of the drugs,
    tests and treatments available today--another reason to digitize modern
    medicine, Corrigan said.
        Many fear that the push to contain costs will result in rationing.
        In today's system, ``we don't ration care, we ration people,'' said
    Donald M. Berwick, president of the independent Massachusetts-based
    Institute for Healthcare Improvement. ``We know that if you are black
    and poor or a woman, there are all sorts of effective interventions you
    are not going to get.''
        Though the transition would be painful and the politics
    treacherous, Berwick said it is possible to spend less on medical care
    and have a healthier nation.
        ``If we could just become La Crosse, think of how much better off
    we would be,'' he said.

        Senator Harkin. Madam Secretary, thank you very much for
    your summation and, as I said, your full statement will be made
    a part of the record in its entirety. So, as we look ahead for
    healthcare reform, people wonder how we are going to pay for
    all this. Well, if one-third, according to the Institute of
    Medicine, is pure waste, that comes out to be about $700
    billion a year. I don't know if that's right or not, but even
    if it's half of that, it seems to me that's an area where we
    could work together and, with the IGs office and others, to
    begin a really concentrated, concerted effort to look at where
    it is that we might make changes.
        You, in your capacity as the Secretary, and where we might
    be able to work with you, should find those areas where we can
    cut down on the waste, and also determine what we can do to cut
    down on the number of infections that people acquire in the
    hospitals. It is becoming dangerous to go to the hospital. More
    and more people are getting sicker in hospitals.
        And so I just throw that out as saying that I hope you will
    be looking at this. You've just come on board, I know you've
    been there, what, a month-and-a-half now? Two months?
        Secretary Sebelius. Six weeks, but who's counting?
        Senator Harkin. Six weeks, okay. Something like that. But I
    would hope that you and your staff would get together and look
    at this and see what it is that you can do, or what we can do
    together, to go after both of those elements.
        Secretary Sebelius. Well, Mr. Chairman, let me just say
    that I appreciate the concern and share it. We have already
    issued a challenge to the American hospitals to work in
    conjunction with our Department to reduce, by two-thirds, the
    number of hospital-related infections. It has been proven that
    using a fairly simple hospital checklist has a dramatic impact
    on hospital infections. So, we are using some of the funding
    provided by Congress in the Recovery Act to do just that. To
    challenge hospitals, and also to increase the State capacity to
    do inspections. That's one area.
        I don't think there is any question that we know where
    there are, as you say, pockets of high-quality, lower-cost
    medical care being delivered day in and day out, but they
    haven't been scaled across the country and there's a lot of
    excessive and redundant care right now that is probably not
    only costly, but doesn't really add anything to the health
    outcome. So that's another area of concern.
        The comparative effectiveness research will help promote
    the best practices and share that patient-centered research
    about what helps and what is most cost-effective. But I can
    guarantee you that, in the Department, we are very focused on
    trying to identify what does work in a cost-effective manner
    and what drives the best health outcomes and hopefully share
    that across the country.
        Health information and technology, again, funded in the
    Recovery Act will have, I think, a dramatic impact on lowering
    medical errors and sharing best protocols and putting some
    transparency behind what is effective or not.
        So, you've already started down the pathway with the
    funding provided in the Recovery Act and there are some more
    investments in this budget that we hope move forward.

                            PREVENTION AND WELLNESS

        Senator Harkin. Madam Secretary, thank you for that
    response. As long as we are talking about the Recovery bill, a
    top priority for me was the Prevention and Wellness Fund. You
    mentioned some of it. Actually, we got $5.8 billion in the
    Senate bill, the final amount was $1 billion, but that's okay.
    We got it. $650 million was dedicated to improve strategies to
    reduce chronic diseases. And we could have, obviously,
    specified exactly where we wanted all of this to go, but we
    left it sort of open, expecting that your Department, and the
    Appropriations Committee, would have an ongoing dialogue about
    what was the best strategy.
        I've heard vague plans about a national media campaign. I
    don't know what diseases or conditions are being considered. I
    understand there might be community grants, but I don't know
    what's being targeted. I guess what I'm saying is that we need
    some more specifics about how you're planning to allocate the
    Prevention and Wellness Fund. And I would like to have your
    assurance that you would consult with us, and have an
    opportunity for us to have meaningful input into this before it
    goes to OMB.
        Secretary Sebelius. Well, Mr. Chairman, you have my
    assurance of that. As you know, Tom Frieden, who was named as
    the new Director of the Centers for Disease Control and
    Prevention, came on board on Monday, yesterday.
        Senator Harkin. Yes.
        Secretary Sebelius. And I think that this is one of the
    significant investments in the Recovery bill and the most
    significant investment in prevention, granted significantly
    under where you hope it would end up, but still the most
    significant investment in prevention and wellness, I think in
    the history of the United States.
        So, the leadership at the Department felt it was very
    important to collect a broad array of ideas and input and I can
    assure you that no final plans have been made. We wanted to get
    the leadership on board and we would be absolutely, not only
    willing, but delighted to consult with you as we move forward.
    Because sharing your expertise, I know this is an area that you
    are passionate about and have a lot of expertise to share, so
    we would very much look forward to coming back to you before a
    plan is finalized.
        Senator Harkin. Outstanding. Look forward to it. Thank you,
    Madam Secretary.
        Senator Cochran.
        Senator Cochran. Mr. Chairman, thank you. Madam Secretary,
    you know, one of the other responsibilities that I've had since
    being in the Senate is to chair the Agriculture Committee, in
    addition to this Appropriations Committee. And it occurs to me
    as we look at things that are done in the rural areas of the
    country, your Department, and the Department of Agriculture,
    share a lot or have some overlapping responsibilities. I wonder
    if you've thought about how maybe these can be coordinated and
    improved efficiencies or, in other ways, make available needed
    benefits like health screening, vaccinations, feeding programs.
    I just thought of those, the WIC program administration, for
    example.
        In the case of a flu virus outbreak, it would be an
    important resource making available vaccinations. Do you have
    any thoughts about whether we need to improve the efficiencies
    of these programs by maybe combining that into one Department
    rather than having a division of responsibility between the two
    departments now?
        Secretary Sebelius. Well, Senator, I can tell you that, in
    my short tenure here at the Department, I have already had a
    number of conversations with the Secretary of Agriculture, Tom
    Vilsack, who I served with as Governors in neighboring States.
    In Senator Harkin's home State, Tom Vilsack was the two-term
    Governor and he was actually Governor when I got elected,
    helped me get elected, and I have learned a lot from him.
        So, there is a lot of collaborative discussion underway.
    Everything from food safety issues, as we redesign the food
    safety initiatives under the Food and Drug Administration, to
    looking at the obesity, food and nutrition in classrooms. A
    couple of the programs that you mentioned we haven't had on our
    radar screen yet, but I think we definitely need to add those.
        The President is very interested and committed to having
    Cabinet secretaries work in a very interagency fashion,
    leveraging the assets of the agencies and not replicating or
    duplicating programs that work well in one area, but borrowing
    good ideas and trying to work together in a collaborative
    fashion.
        So, I think you've made some important suggestions and I
    will certainly circle back with those with the Secretary of
    Agriculture.

                           LIHEAP FUNDING DISPARITIES

        Senator Cochran. The President's budget request creates a,
    or suggests that there should be created, a new mandatory
    LIHEAP program with a trigger mechanism for automatic increases
    in energy assistance. Under the current formula, these funds
    are distributed more to cold weather States than they are warm
    weather States, at least that's my observation.
        When the new LIHEAP program is designed, how do you intend
    to address the funding disparity that endangers lower income
    residents in rural States in the South?
        Secretary Sebelius. Well, Senator, I have to tell you that
    I wasn't aware of the disparity until I began some of the
    visits in preparation for my confirmation hearing. And it was
    raised by a number of warm weather Senators that the money runs
    out before it gets hot in the summertime.
        And what I said at that point, and I intend to continue to
    do, is to take a look at the way that the funds are
    distributed. Because I agree with you, people are in jeopardy
    if they're sitting in 100 degree homes, the same way they are
    if they are in 30 degree homes. And the same kind of impact is
    had on vulnerable populations.
        So, I can assure you that we would not only appreciate your
    input, but that I will certainly take into consideration, and
    ask the folks who are administering the program, if we are
    looking at the issues of warm weather States, because I think
    it is of concern.
        Senator Cochran. Thank you. I have a couple more questions,
    but I am going to yield to other senators who are here.
        Senator Harkin. Senator Kohl.
        Senator Kohl. Thank you so much. Secretary Sebelius,
    welcome.
        Secretary Sebelius. Thank you.
        Senator Kohl. As you know, the waiver for Wisconsin's
    Senior Care Program is scheduled to end on December 31 of this
    year. Currently, this program provides over 100,000 seniors in
    my State with high-quality, cost-effective prescription drug
    coverage, as I presume you are aware. According to the CBO, it
    does so while achieving ongoing savings for the Federal
    Government at the same time.
        I understand that Governor Jim Doyle, who I know you are
    very familiar with has applied for a waiver to extend senior
    care through 2012, which should allow this very successful
    program to continue. Can you tell me the status of the waiver
    application and whether or not we can hope to achieve that
    waiver?
        Secretary Sebelius. Well, Senator, as you know, that 1115
    Program is the only one left in the country where the State-
    only drug program is being conducted. And I know it's wildly
    popular and I know it's been enormously successful. You'll be
    pleased to hear that not only did my good friend, Jim Doyle,
    apply for the waiver of continuation before I got to the
    office, but he was in my office 3 days ago amplifying that
    request, to make sure that I did not forget. And, as you might
    be aware, the President is going to Green Bay, Wisconsin on
    Thursday to talk about healthcare reform and I don't doubt that
    he's going to hear a little bit of something about this popular
    program.
        It is my understanding that we're in the final stages of
    review, that people in the Agency are aware of not only how
    popular it is, but how successful it's been. And I'm hopeful
    that we will be able to give you news in the very near future.
        Senator Kohl. Well, I'll take that as a somewhat positive
    indication.
        Secretary Sebelius. I just don't have the definitive answer
    today. I'd hoped I'd have it by today, but close.
        Senator Kohl. Okay. I happen to have given a speech on
    Monday in Wisconsin to 400 people who are involved in issues
    that apply to seniors all across our State and I had something
    like a dozen applause lines written into my speech. The only
    one that got any applause----
        Secretary Sebelius. Was this program.
        Senator Kohl [continuing]. Was my reference to the senior
    care program and how effective it's been.
        Secretary Sebelius. Well, I can tell you in the discussions
    that I've been involved in healthcare reform, I have asked our
    folks, just because before I came to this position, as a
    Governor and as someone who shared ideas with other governors,
    not only did I have our State looking at how successful
    Wisconsin had been and what kinds of things we could do to
    mirror it, but the healthcare reform team has the whole program
    and we want to look at it as a possibility to include as one of
    the options.
        So, it definitely has caught the attention of lots of folks
    outside of Wisconsin.

                             QUALITY OF HEALTHCARE

        Senator Kohl. Thank you.
        Secretary Sebelius, lately, as I'm sure you're very much
    aware, there's been much media attention on how it costs two to
    three times as much to fund a Medicare recipient in some
    locales across our country than it does in others. We've seen
    articles in several publications come to the conclusion that
    healthcare quality does not increase with higher spending. In
    fact, The Washington Post reports that healthcare costs in a
    place in my State, Lacrosse, are much lower than the national
    average and yet quality is much better than the national
    average.
        I'm sure this is one of the toughest, one of the toughest
    problems that you are going to be confronting in your time as
    Secretary. Do you have some initial thoughts on what we can do
    to take advantage of those areas that are doing a great job in
    controlling costs and extend it across the country to those
    areas that are not?
        Secretary Sebelius. Well, Senator, I think you've just very
    adeptly defined the challenge as how to take what is happening
    in pockets, as Senator Harkin said earlier, across the country
    and sort of scale up. So not only do we reduce overall costs,
    but we increase quality.
        Someone said to me the other day that, you know, there's a
    lot of discussion about rationing healthcare. And this expert
    said that he thought what we were doing currently in America
    was rationing quality, which I thought was an interesting lens.
    I think the comparative effectiveness research that was funded,
    $1 billion worth in the Recovery Act, is a big step in that
    direction. To inform doctors and consumers, patients, what is
    happening and what the best practices are. I think there are
    certainly NIH studies which can lend to that and CDC is looking
    at areas that we can improve quality.
        But part of it is learning from the folks who are running
    the health systems that have been identified as delivering
    high-quality care at a much lower cost. We have some
    improvements currently proposed in the budget and some Medicare
    demonstration projects. One of the areas we know is very
    erratic is what happens to a patient when you get released from
    a hospital. Right now, 20 percent are re-admitted. And a lot of
    evidence leads to the fact that that's because of a lack of
    follow-up care, which is very expensive and certainly not great
    for the patient. So, we're trying to expand best practices in
    that area.
        Looking at bundled payments so providers are more concerned
    with ultimate outcome and not with contacts with patients. So
    we think that will be an effective strategy. And really
    driving, encouraging some voluntary collaboration, with single
    practice docs so that they can have a more coordinated care
    strategy.
        So trying to take what we think is working and encourage
    others to follow that practice and use some of the Medicare,
    both incentives and payments, to enhance and accelerate quality
    care for all Americans.
        Senator Kohl. Thank you very much. Thank you very much, Mr.
    Chair.
        Senator Harkin. Thank you, Senator. Senator Alexander.
        Senator Alexander. Thank you, Mr. Chairman. Madam
    Secretary, welcome. I'm glad you're here.
        The President sent a letter to Senator Baucus and Senator
    Kennedy saying that, on June 2, saying that healthcare reform
    must not add to our deficit over the next 10 years and today he
    made a speech about pay-go, saying that we should only spend a
    dollar if you save, or I might add tax a dollar. Are we to
    assume then that so-called pay-go should apply to the
    healthcare reform bill that we are considering in Congress.
        Secretary Sebelius. Well I think, Senator, certainly the
    estimates over a 10-year period of time are a bit difficult to
    reach. And I think one of the ongoing concerns, and it is
    something that I think the chairman shares, is that currently
    there is no scoring, for instance, for any prevention and
    wellness strategy. I'm not sure there's an expert who believes
    that it won't save money, and yet it is not scored.
        So, whether or not the kind of transformational healthcare
    reform will actually have a dollar-for-dollar offset on day
    one, I can't tell you because I think that----
        Senator Alexander. So, pay-go does not apply to the
    healthcare reform bill we are considering?
        Secretary Sebelius. Senator, I think it does. I haven't
    seen the outlines of exactly what the President is proposing to
    Congress. I know there was some discussion, about the 10-year
    timeline with the healthcare reform bill. Is it 10 years from
    the date it starts, is it 10 years from the date it passes? And
    there is a lively debate about prevention and wellness
    strategies and whether that can be scored at least in out-
    years.
        Senator Alexander. But would you agree that it might be a
    good idea to see the details of the proposal and to hear from
    the Congressional Budget Office what the scoring might be
    before making a decision about going forward, in light of the
    President's concern about pay-go?
        Secretary Sebelius. Well, I think certainly it is a
    discussion to have. I'm not sure that the Congressional Budget
    Office is going to score prevention, although I think they're
    dead wrong in not assuming that there will be savings and cost
    effectiveness related to shifting a health system to a wellness
    prevention system.
        Senator Alexander. Well, without being overly redundant, if
    the President is going to write us a letter and say don't add
    to the deficit and give us a lecture about pay-go, shouldn't it
    apply to the healthcare reform bill, which is variously
    estimated between $1 to $2 trillion in new costs over the next
    year?
        Let me ask you this, if it does cost between $1 to $2
    trillion, depending upon whether it's the Kennedy bill or the
    bill being considered by the Finance Committee, what new taxes
    or what new savings would the administration recommend to make
    sure that we don't add to the deficit?
        Secretary Sebelius. Well, Senator, as you probably know, in
    the 2010 budget, the President recommended about $630 billion
    worth of both savings and revenue enhancements. And we've also
    suggested, after reviewing the overall Medicare programs, that
    within the Medicare program, we think another $200 to $250
    billion is possible in terms of savings. There's no question
    that the additional and enhanced efforts on fraud and abuse
    will generate some additional savings. And he has had lively
    discussions with members of the House and the Senate about
    their ideas for funding the remainder of the program.
        But I think the good faith effort by the President, and
    it's demonstrated in his budget and moving forward, to come in
    with a substantial investment in reform moving forward, and
    then hopefully engaging Congress in that very discussion.
        Senator Alexander. But you would agree that the investment
    is only a beginning of the amount of money that we may need?
        Secretary Sebelius. Well, $634 billion plus another $200
    billion is $800 billion. And if it is in the $1 trillion to
    $1.2 trillion range, that's a pretty good investment moving
    forward.
        Senator Alexander. That's a pretty good investment, so it
    would be important to know the details of the proposal and the
    cost of the proposal before we vote on the proposal and act on
    the proposal, if we are to take, show respect to the
    President's desire for pay-go and not adding to the deficit.
        Secretary Sebelius. Well, and hopefully as Members of
    Congress engage in this discussion, as the bill is written by
    the Finance Committee and the HELP Committee, the three
    committees dealing with it in the House will engage in those
    conversations about paying for healthcare reform, which will be
    a critical part of this dialogue moving forward.

                        A PUBLIC HEALTH INSURANCE OPTION

        Senator Alexander. Does the President or the administration
    support the Government-run insurance plan proposed by Senator
    Kennedy in his legislation? I note that the President, in his
    letter, said that he wanted to see a public or Government-run
    option as a part of a plan.
        Secretary Sebelius. Well, I think that the President has
    maintained from the outset, during the course of the campaign
    and in the letter that you received, that in the Health
    Insurance Exchange, a marketplace where consumers would have
    choices and options for coverage if they want to choose new
    coverage, that a public option is very important. In many parts
    of the country, there is not a choice of private plans. There
    is a dominant carrier, a monopoly----
        Senator Alexander. Excuse me, but does he support or not
    support Senator Kennedy's----
        Secretary Sebelius. I have not seen the specific language
    that you are referring to----
        Senator Alexander. So, he would want to read it and
    understand it and understand it and maybe see the cost of it
    before he made that decision.
        Secretary Sebelius. You'd have to ask the President about
    that.
        Senator Alexander. Well, I'm asking--you represent him,
    would you want to read it and understand it?
        Secretary Sebelius. And I will.
        Senator Alexander. And know the cost of it before you
    decided whether you supported it.
        Secretary Sebelius. I'm sure we'll have that dialogue.
        Senator Alexander. Does that mean you would or you
    wouldn't?
        Secretary Sebelius. I said I would read it, yes sir.
        Senator Alexander. So, you would want to read it and
    understand the cost before you decided whether to support it.
        Secretary Sebelius. Yes, I will read it.
        Senator Alexander. Thank you, Mr. Chairman.
        Senator Harkin. I just want to make sure my colleague from
    Tennessee, who is also a member of the authorizing committee, I
    believe, right?
        Senator Alexander. Yes.
        Senator Harkin. That we're going to have a walk-through
    with our bill starting tomorrow, both Republicans and
    Democrats, that the Senator will have every opportunity to
    amend, offer, discuss these different things. I can tell you to
    right now that we're on this public option plan, that we're
    leaving it blank, because we want to have a discussion on it.
    And we want to have ideas that come forward, and see where the
    votes are. I think that's the fair and honest way to do that.
        So, we're not coming out with anything and saying here is,
    take it or leave it. We are kind of leaving it open for
    discussion and then I we'll see where the votes are on it. I
    think that's the best way to proceed.
        And then, after that, whatever we decide to do, then the
    administration can tell us what they think, but that's our deal
    and we have to do it.
        Senator Alexander. I thank the chairman. I just wanted to
    establish the principle that it is usually a good idea to read
    and understand know the cost of a proposal before we are asked
    to make a decision about it.
        Senator Harkin. Oh, I think that will happen in the next
    couple months. Senator Pryor.
        Senator Pryor. Thank you, Mr. Chairman, and thank you,
    Madam Secretary, for being here.
        Let me start, if I may, with the issue of Comparative
    Effectiveness Research. And my understanding is that this
    research has great potential to empower patients and physicians
    to choose treatments that offer the most benefit; however, some
    have attacked this initiative, claiming that it could be used
    to ration care.
        Do you mind talking to the subcommittee for a few minutes
    about Comparative Effectiveness Research and why you think that
    the Department is in a better position than the private sector
    to ensure this research is performed?
        Secretary Sebelius. Well Senator, I think that, first of
    all, to the point you made citing detractors who are fearful
    that this will lead to rationing care, there is a provision in
    the funding of the research that prohibits Medicare from using
    Comparative Effectiveness Research to make cost decisions. I
    think that is clear in the law and certainly the folks at the
    Centers for Medicare and Medicaid Services (CMS) intend to
    follow the law.
        We are very encouraged by the opportunity to learn from
    what's happening in this rapidly evolving area of medical care
    and certainly what is happening to produce high-quality, low-
    cost care in various parts of the country. And to help drive
    those best practices across the country, so all Americans have
    access to that care. And I think that the investment that
    Congress wisely made in Comparative Effectiveness Research
    gives us the opportunity to do that, to tie in what strategies
    lead to better health outcomes and lower cost which are, again,
    in places in pockets around the country, but not everywhere.
        And I think the fear is that somehow this will drive
    rationing of care. I will suggest it will raise quality of care
    in a very effective manner.

                       HEALTHCARE ACCESS IN RURAL AMERICA

        Senator Pryor. Let me ask another question, something that
    I know is important to you, being from a rural State like I am.
    And that is that we have a real challenge in our State, as well
    as other senators do in their home States, where we just don't
    have enough doctors in rural America.
        And my sense is that, you know, one reason is because a
    rural setting and the challenges for a rural practice just
    isn't that appealing for a lot of people coming out of medical
    school. But also, I think that there is a practical part of
    this and that is that the Medicare reimbursement rates are
    often much lower in a State like Arkansas, and may be your home
    State, and elsewhere than they would be otherwise.
        Secretary Sebelius. We like to call you ``Our Kansas''
    but----
        Senator Pryor. I understand, I understand. We get that a
    lot by the way. But we do share that, so my question for you
    is, what is the best way to ensure that people in rural America
    have, not access to coverage, but actually access to care in
    their home communities?
        Secretary Sebelius. Well, I think it's a great question and
    certainly one that I worked on as Governor in Kansas, and I
    share your concerns about the distribution of healthcare
    providers and the incentive to stay in practice in a rural
    community.
        Certainly continuing to examine the pay differentials of
    Medicare is a piece of the puzzle and one that I take seriously
    and will make sure that we continue to look at. Whether or not
    that provides disincentives for all kinds of things. There are
    people who suggest that there are also disincentives for lower-
    cost care to be delivered in some areas because then they turn
    around and get penalized with lower reimbursement rates.
        I think there's a lot that the investment that you made in
    health technology can also do to enhance rural practitioners by
    connecting with telemedicine to specialists and consultation
    experts who may be hundreds or even thousands of miles away,
    but can be very much part of their practice on an ongoing
    basis. And certainly the investment in the Expanded Commission
    Corps to look at underserved areas is a help, as well as the
    money--we just announced a couple of days ago, pushing out the
    door some of the Recovery Act money which will help pay student
    loans. And I know, at least in our State and I'm sure in
    Arkansas, the payment strategy for underserved areas has been
    particularly effective in having young providers locate. And
    once they are there, they don't leave, that has been our
    experience.
        So, I think we've got to use a whole variety of incentives,
    loan repayment, telemedicine, to make sure that all Americans
    have high-quality care.
        Senator Pryor. Well, and I do appreciate the President and
    you putting into the budget the Improved Rural Health Care
    Initiatives. So, I think that's a step in the right direction.
    Thank you for your answer.
        Mr. Chairman.
        Senator Harkin. Thank you, Senator. Senator Specter.
        Senator Specter. Thank you, Mr. Chairman. Madam Secretary,
    thank you for taking on this difficult job and leaving the
    beautiful State of Kansas.
        Secretary Sebelius. Our home State, I share with the
    Senator, yes.
        Senator Specter. Today has been a Kansas Day in
    appropriations hearings. Secretary Gates testified this
    morning. He's from Wichita.
        Secretary Sebelius. Yes, indeed.
        Senator Specter. And went to a very distinguished grade
    school.
        Secretary Sebelius. We're talking about Kansas, it's
    important.
        Senator Specter. He went to a very distinguished grade
    school and it's called College Hill. It only went to the sixth
    grade. And I went there not quite at the same time, but the
    same school. And the Governor is from Kansas in a town not too
    far from Russett.

                                  NIH FUNDING

        So much for the pleasantries, Governor. Now on to your
    budget. To have an NIH budget of $442 million is a sharp
    retreat from what the chairman used to insist on, $3.5 billion
    a year increases. Senator Harkin wouldn't settle for any less
    than that for most of a decade. Well, I guess that's not
    entirely true, occasionally he settled for $3 billion. But if
    you take a look at the cost-of-living adjustments, the
    inflation rate, about 3.3 percent, that's $1 billion.
        I know you don't construct the budget all by yourself, OMB,
    there are lots of constraints, but I would urge you to take
    another look at that figure. We can offer amendments, of
    course, to stay within the budget, but I appreciate it if you
    would take another look at it.
        The $10 billion which was added in the stimulus package has
    created an enormous wave of excitement among young people. We
    are in jeopardy of losing a generation of young research
    scientists and I think we have to maintain the growth rate. We
    talk about cutting down the costs of healthcare, what better
    way to cut the cost factor than to prevent illness. And during
    the period of time when Senator Harkin had his way, increasing
    from $12 to $30 billion, the death rate from----
        Senator Harkin. Wait a minute, I was ranking member.
        Senator Specter. What's that? Now, come to think of it, he
    didn't have all that much to do with it. But on a serious note,
    we used to trade gavels with some frequency. But on to the
    serious note, the death rate from strokes went down, from heart
    disease, improvements on cancer. And we just have to find some
    way to do better.
        And I note that the budget calls for $268 million for
    cancer and $19 million for research into autism. That is a
    change from what we've always done. We'll have endeavored not
    to politicize the allocations by leaving it to the scientists.
    And one year the chairman of the Appropriations Committee who
    suffered from prostate cancer wanted to add $150 million to
    prostate cancer and he was unsuccessful in doing that.
        So, I'd like you to take another look. And I know you can't
    focus on all of these matters and you don't have a long history
    like this subcommittee as to whether you really want to
    initiate a policy of picking and choosing.

                 UNIVERSITY OF PITTSBURGH BIODEFENSE INITIATIVE

        My yellow light is on so I will make only one further
    comment. I want to express my thanks to you for meeting with a
    group by May 20 on the Biodefense Initiative from the
    University of Pittsburgh, UPMC. Do you have any initial
    thoughts on that subject? I know you haven't had time to go
    through it in detail, but any preliminary thinking? I don't get
    calls from UPMC more than twice a day, so when I have you here,
    I thought I'd ask.
        Secretary Sebelius. Well Senator, I thought, first of all,
    the presentation was very impressive and certainly the notion
    that we should have a facility dedicated to production of a
    variety of vaccine lines is also incredibly timely and
    something that I think should be part of our preparedness
    arsenal.
        I think that the issue that we're facing right now, as you
    well know, is whether we can adequately prepare for the
    uncertainties that still may be confronting us in the very near
    future with novel H1N1 strains, and the potential massive
    vaccination program, and production costs, and continue with
    the preparedness underway. And then add an additional factor to
    that. But I don't think there's any doubt about the importance
    about that being part of the strategy moving forward, but how
    quickly that could be implemented, I can't tell you right now.
        Senator Specter. Well, we would appreciate your informing
    us at the earliest date you can.
        Secretary Sebelius. I will, Senator. Thank you.
        Senator Specter. Thank you, Madam Secretary and thank you,
    Mr. Chairman.

                              NIH STIMULUS FUNDING

        Secretary Sebelius. And Senator, may I just respond briefly
    to the research questions, because I just want to tell you that
    I share both the concern that we continue to invest in science
    and research. And I have already heard enormously positive
    feedback about the investment from the Recovery Act and, as you
    say, the excitement of a new generation of researchers that we
    are recommitting to research funding.
        I do think that, in putting together the 2010 budget, there
    was a recognition that the Recovery Act funds really will fund
    2010 and some of the 2011 strategies. But working with you,
    Senator, not only Senator Specter, but the chairman, who I know
    has enormous interest in this research area, on future years I
    think will be very important to make sure that we don't reach a
    cliff and fall off the edge of the cliff, because we want to
    continue this multi-year research investment.
        Senator Specter. Well, Madam Secretary, may I suggest that
    the stimulus package and that $10 billion ought not to be
    looked at for the regular funding. That is extra, designed to
    create 70,000 new jobs for the 2-year period, with the specific
    target that the President asked for and that Congress responded
    to in an affirmative way.
        I perhaps, as much as any, under the circumstances casting
    the vote I did, that we were looking for that to stimulate the
    economy and for jobs. And I couldn't tell you, line by line, on
    all the other budget items, but I believe that it was not a
    generalization for the stimulus to be used in place of the
    future years' funding.
        So we'd like to maintain NIH funding on its own, besides
    that.
        Senator Harkin. Madam Secretary, I just want to say that I
    fully concur with Senator Specter's views on this. We have
    worked in tandem on this for a long time and I can assure you
    that, when it comes to NIH funding, regardless of which side
    Senator Specter is on, he is going to be dogged on this and I
    am going to be joining with him on it.
        Senator Specter is absolutely right. We put that money in
    there, in the stimulus, because it was stimulus for the 2
    years. And I am concerned about the cliff and the baseline and
    what happens to that baseline funding.
        Quite frankly, if you really look at it, Senator Specter,
    we finished that from about 2005 until now, basically our
    funding has been kind of flat. I think that in real dollars we
    are about at where we were in 2005, if I'm not mistaken. So, to
    only put in $442 million doesn't do much for getting our
    baseline up.
        Senator Specter. Mr. Chairman.
        Senator Harkin. Yes.
        Senator Specter. During the period of the last several
    years, you and I made the calculation we went down $5.2 billion
    in real dollars.
        Senator Harkin. Real dollars, yeah.
        Senator Specter. As a result of not having a cost-of-living
    adjustment for several years and then these tiny across the
    board cuts, a percent here and half a percent there, and pretty
    soon a $30 billion allocation turns out to be less than $25
    billion. So, were playing against that backdrop as well.
        Senator Harkin. So, this one thing we can probably concur
    on, I don't know about the second, but the $442 million is, I
    think, inadequate. We'll see what we can do about that. I don't
    know, within our allocation, what we can do. We don't have our
    allocation yet, we'll have to see about that. But we have a lot
    of demands for this and we'll just have to see what we can come
    up with.
        But within that $442 million, I am somewhat concerned that
    $268 million was designated for cancer, for the National Cancer
    Institute, and I think, $19 million for autism. So, over half
    of that for two Institutes, for two diseases. And I mentioned
    this to the NIH Director, Acting Director, who was up here
    looking at their budget, that I don't know if this is a good
    way to do things. To put all that money just into those two
    programs, when there's a lot of other needs spread across the
    entire spectrum of research.
        And I'm just thinking that, perhaps, we might look for a
    better distribution of the money than just in those two areas.
    Let the researchers at NIH decide where that money ought to go.
        Secretary Sebelius. I appreciate that.
        Senator Harkin. I don't have anything else, Madam
    Secretary.

                           HEALTHCARE FRAUD AND ABUSE

        Senator Cochran. Mr. Chairman, I have one other question,
    if I may.
        Madam Secretary, I've been advised that fraud and abuse are
    draining about $60 billion a year from our healthcare system.
    This money could be going to patient care and to address other
    problems. I've co-sponsored, with other senators, The Seniors
    and Tax-payers Obligation Protection Act, as an acronym STOP,
    it's known as the STOP Act, which is designed to eliminate the
    use of Social Security numbers as the Medicare identifier to
    help curb fraudulent services.
        I wonder if you agree that something like that is needed
    and, in view of the fact that your budget includes only $113
    million for Medicare safeguards, do we need to look elsewhere
    for ways and means of helping to curb Medicare waste, fraud,
    and abuse?
        Secretary Sebelius. Well, I certainly share your concern
    about waste, fraud, and abuse, Senator. And any dime stolen
    from the program is stolen from not only the taxpayers, but
    from the delivery of healthcare services. And I think that's
    why the President was eager to have the Attorney General and I
    join together in a new initiative sharing real data, rather
    than following what were sometimes old audits, trying to get
    out ahead of some of this effort by monitoring billing.
        And I am not familiar specifically with the legislation you
    mentioned, but I will certainly share those ideas with our
    folks and have them take a look at it. Because I think that
    anything we can do to discourage these practices before they
    occur and save those resources for the delivery of healthcare
    is incredibly important.
        People are stealing from the system and we want to make it
    more difficult, if not impossible, not easier. So, this is one
    strategy that I would love to take back to our CMS folks.
        Senator Cochran. Thank you very much. Thank you, Mr. Chair.
        Senator Harkin. Thank you, Senator Cochran.

                         ADDITIONAL COMMITTEE QUESTIONS

        Well, Madam Secretary, thank you very much for your
    appearance here and your leadership at the Department. I will
    leave the record open for any written questions that the
    Senators who couldn't be here might want to propound. And,
    again, I look forward to working with you on the recovery money
    that we talked about before that's going out for prevention.
        Secretary Sebelius. Absolutely. Thank you.
        [The following questions were not asked at the hearing, but
    were submitted to the Department for response subsequent to the
    hearing:]
                Questions Submitted by Senator Daniel K. Inouye
                occupational safety and health training program
        Question. Several years ago, at my request, the Centers for Disease
    Control and Prevention (CDC) established a National Institute for
    Occupational Safety and Health presence at the University of Hawaii at
    Hilo. Unfortunately, a now retired faculty member returned the funds.
    With new and energetic faculty now present, will you consider re-
    establishing a presence back on the island, given our truly unique
    rural and environmental needs?
        Answer. CDC/NIOSH supported a Training Project Grant at the
    University of Hawaii--Hilo (T02-OH008627, entitled ``Occupational
    Safety and Health Education--A Behavioral Approach,'' from August 2001
    through June 30, 2006. The awarded application was competitively
    reviewed and was awarded based on its technical and scientific merit.
    The Principal Investigator, Dr. Stephen Worchel, Department of
    Psychology, indicated to CDC/NIOSH in August 2005 that the University
    did not plan to recompete for support of this project. The grant ended
    and was subsequently closed out.
        On March 12, 2009, CDC/NIOSH provided a step-by-step process for
    submitting a new application to University of Hawaii at Hilo for a
    Training Project Grant. University officials indicated that the
    University of Hawaii--Hilo planned on submitting a highly competitive
    application for the upcoming August 24 deadline in response to NIOSH's
    Program Announcement PAR-06-484: http://grants.nih.gov/grants/guide/pa-
    files/PAR-06-484.html. The most meritorious applications are expected
    to be funded in June 2010.
                           native hawaiian healthcare
        Question. I am very pleased that your department continues to
    recognize the unique health needs of the Native Hawaiian population. I
    appreciate being kept informed of efforts to improve health outcomes,
    especially as they relate to diabetes and cancer in this population.
        Answer. The Department of Health And Human Services (HHS) has a
    number of initiatives, grants, and partnerships to address the needs
    the Native Hawaiian population; attached is a list of some of the
    grants provided to organizations serving Native Hawaiians. In 2006, HHS
    established the HHS Workgroup on Asian, Native Hawaiian and other
    Pacific Islander Issues (WANHOPII). The mission of WANHOPII is to
    improve communication, coordination, and agency policies, programs, and
    evaluations that impact the health, healthcare, human services, and
    well being of Asian American, Native Hawaiian and other Pacific
    Islander (NHOPI) communities. In addition, the Office of Minority
    Health is supporting the development of the Native Hawaiian and Other
    Pacific Islander Health Agenda, including town hall meetings and
    summits that provide a forum for NHOPI community members, community-
    based organizations, and others to voice their issues, concerns, and
    recommendations, and to mobilize around a health and well-being agenda
    to address NHOPI health.
        Several HHS offices and agencies have programs to improve health
    outcomes, including those related to diabetes and cancer, of the Native
    Hawaiian population. Summaries are provided below:
                           office of minority health
        The Office of Minority Health (OMH) supported the development of
    the Native Hawaiian and Other Pacific Islander Health Agenda introduced
    by the Asian and Pacific Islander American Health Forum (APIAHF), and
    provided additional funding to APIAHF to explore health issues facing
    Native Hawaiians and Pacific Islanders.
        In April 2007, OMH supported the California Native Hawaiian and
    Pacific Islander Town Hall Meeting to provide a forum for NHOPI
    community members, community-based organizations, and others working
    with NHOPI populations to voice their issues, concerns, and
    recommendations regarding NHOPI health to the HHS. The town hall and
    subsequent discussions resulted in the first ever Native Hawaiian and
    Pacific Islander Health and Well-Being Summit in October 2007 to
    articulate and mobilize around a health agenda. HHS recognizes that
    NHOPI communities have unique health needs, and has supported APIAHF in
    the formation of the Native Hawaiian and Pacific Islander Alliance. On
    January 30, 2008, APIAHF with the NHPI Alliance released the report
    ``Guidance for the classification of Native Hawaiians and Pacific
    Islanders'' that appropriately reflects the disaggregation of Asian
    Americans, Native Hawaiians, and Pacific Islanders.
        In April 2009, OMH co-sponsored the Native Hawaiian and Pacific
    Islander Health Brain Trust, hosted by the APIAHF. The 2009 Brain Trust
    was the first of a two-series conference to learn about pressing health
    issues and discuss barriers to data collection and reporting on Native
    Hawaiians and Pacific Islanders, and to identify strategies for
    community and community-based organizations, researchers, funding
    agencies, policy makers, and advocates for improving the health and
    well-being of Native Hawaiians and Pacific Islanders.
        OMH also works closely with our community partners, including Papa
    Ola Lokahi, to respond to the concerns and needs of the Native Hawaiian
    community. Through the Youth Empowerment Program, OMH supports the
    Lanakila Learning Center through the University of Hawaii at Hilo. The
    Lanakila Learning Center is an alternative learning center of Hilo High
    School servicing ``at-risk'' 10th-12th graders, and providing a variety
    of wellness workshops in substance abuse prevention/intervention,
    social skills training, anger management, health and nutrition, and
    fitness classes.
        Through the Community Partnerships to Eliminate Health Disparities
    grant program, OMH supports the Life Foundation, a program that seeks
    to improve the health status of Native Hawaiians, Asians, and Pacific
    Islanders through targeted HIV prevention and care services. Life
    Foundation partners with Waikiki Health Center and Waianae Coast
    comprehensive Health Center.
                  health resources and services administration
        The Health Resources and Services Administration (HRSA) provide
    funding for the Native Hawaiian Health Care Program, which is funded
    through the Health Center appropriation. The focus is to improve the
    health status of Native Hawaiians by making health education, health
    promotion, and disease prevention services available through the
    support of the Native Hawaiian Healthcare Systems. The Native Hawaiian
    Healthcare Systems use a combination of outreach, referral, and linkage
    mechanisms to provide or arrange services. Services provided include
    nutrition programs, screening and control of hypertension and diabetes,
    immunizations, and basic primary care services. In fiscal year 2007,
    Native Hawaiian Healthcare Systems provided medical and enabling
    services to more than 6,500 people. The Native Hawaiian population is
    also served by the Health Centers operating more broadly across Hawaii.
          niddk's diabetes education in tribal schools (dets) project
        The National Institute of Diabetes and Digestive and Kidney
    Diseases (NIDDK) has provided funding to eight tribal colleges and
    Universities to develop supplemental curricula on diabetes education
    for K-12 schools that educate American Indian and Alaska Native
    children. The curricula are completed and the investigators are now
    recruiting and training teachers in the K-12 schools. Recently, the
    investigators were invited by some schools in Maui to provide
    professional education to their teachers so they can also use the DETS
    curricula to teach children in their K-12 schools about diabetes and
    prevention. You may find more information on the DETS at: http://
    www3.niddk.nih.gov/fund/other/dets/index.htm.
                    hhs national diabetes education program
        The HHS National Diabetes Education Program (NDEP) is the leading
    Federal Government public education program that promotes diabetes
    prevention and control. Launched in 1997, NDEP's mission is to reduce
    the morbidity and mortality associated with diabetes. More than 200
    organizations and many volunteers have joined with NDEP to help develop
    critical and effective initiatives. The NDEP Asian American and Pacific
    Islander Work Group has led development of tip sheets on comprehensive
    diabetes control and the primary prevention of diabetes in 15 Asian and
    Pacific Islander languages. Through the CDC, the NDEP supported Papa
    Ola Lokahi's Pacific Diabetes Education Program, serving Native
    Hawaiians and a diverse population across the Pacific Islands with
    culturally appropriate in-language diabetes materials.
        The Hawaii Diabetes Prevention and Control Program (HI DPCP) has
    received funding from the CDC since 1987. Activities supported by the
    DPCP include surveillance, development of the Hawaii Diabetes
    Coalition, translation, development and distribution of resource
    materials, quality improvement initiatives, and review of the Hawaii
    State Practice Recommendations.
                   centers for medicare and medicaid services
        Many of the Centers for Medicare and Medicaid Services (CMS)
    activities have focused on the Native Hawaiian healthcare system (Papa
    Ola Lokahi is the lead agency) along with grants to various Federally
    Qualified Health Centers (FQHCs) and community health centers. CMS also
    funds a Cancer Prevention and Treatment Demonstration for Racial and
    Ethnic Minorities (ending in 2010) at Molokai General Hospital. The
    demonstration is using a randomized control design to study the impact
    of various evidence-based, culturally competent models of patient
    navigator programs designed to help minority beneficiaries navigate the
    healthcare system in a more timely and informative manner and
    facilitate cancer screening, diagnosis, and treatment to improve
    healthcare access and outcomes as well as potentially lower total costs
    to Medicare. Approximately 12,700 Medicare fee-for-service
    beneficiaries are eligible to be enrolled in the study during this 4-
    year project.
        Through CMS-funded grants directed to States, State Health
    Insurance Assistance Programs, or SHIPs, provide free counseling and
    assistance to people with Medicare and their families. The Hawaii SHIP
    provides the following activities:
      --Part D/LIS and general Medicare counseling, information and
            outreach to beneficiaries and information on how the plans will
            coordinate with the unqualified SPAP which will lead to
            improved access to medications by beneficiaries. While this is
            not specifically targeted to diabetes and cancer health
            outcomes, these activities will help improve access to needed
            medications for this population.
      --Through the Executive Office on Aging of the Department of Health
            where the SHIP is housed, the Native Hawaiian programs
            participate in the Healthy Aging project.
                            administration on aging
        With funding from the U.S. Administration on Aging, Hawaii's
    Executive Office on Aging and Department of Health work together to
    offer Healthy Aging Partnership--Empowering Elders (HAP-EE), which
    began in September 2006. HAP-EE carries out programs that have been
    proven effective in reducing the risk of disease, disability and injury
    among the elderly. These include the Chronic Disease Self-Management
    Program, Arthritis Self-Management Program, Diabetes Self-Management
    Program, and EnhanceFitness. These programs provide seniors with simple
    tools and techniques they can use to better manage their chronic
    conditions, reduce their risk of falling, and improve their nutrition
    and physical health. A pre-poststudy of the Hawaii Chronic Disease
    Self-Management Program reported improvements in physical activity;
    reductions in pain, fatigue and shortness of breath; and a reduction in
    medical care use. Results of pre-poststudy of Enhance Fitness
    participants in Hawaii showed improvements in gait and strength,
    increased levels of physical activity, and reduction in falls.
                   centers for disease control and prevention
        The Division of Cancer Prevention and Control provides funding to
    the Hawaii Department of Health, through a cooperative agreement, to
    provide breast and cervical cancer screening and diagnostic services to
    underserved women, including Native Hawaiian women. The Division of
    Cancer Prevention and Control also provides funding to the Hawaii
    Department of Health for the Comprehensive Cancer Control Program.
    Hawaii has a comprehensive cancer control plan that was developed by a
    coalition that includes a diverse group of stakeholders. Coalition
    members include representatives of organizations, such as Papa Ola
    Lokahi, that focus on the needs of the Native Hawaiian population.
                         office on women's health (owh)
        Advancing System Improvements to Support Targets for Healthy People
    2010 (ASIST2010) is a 3-year cooperative agreement program funded by
    the Office on Women's Health. ASIST2010 uses a public health systems
    approach to improve performance on objectives that target women and/or
    men in the following focus areas: cancer, diabetes, heart disease,
    stroke, access to quality health services, educational and community-
    based programs, nutrition and overweight physical activity, and
    fitness. Two of the 12 funded ASIST2010 programs targeting diabetes
    include as their target population Pacific Islanders:
      --National Kidney Foundation of Michigan (Ann Arbor, Michigan).--The
            site utilizes PATH, Tomando Control de su Salud and Enhance
            Fitness programs to provide people with chronic diseases and
            those at-risk with the skills and tools needed to improve their
            health outcomes and manage their symptoms. To assure that the
            programs are culturally appropriate, leaders and programs are
            gender-specific as needed to reach certain racial and ethnic
            minority populations, including African Americans, Hispanic/
            Latinos, Asian Americans/Pacific Islanders, Native Americans,
            and Arab Americans.
      --Wise Woman Program of Saipan, Commonwealth of the Northern Mariana
            Islands.--The Wise Woman Village Project (WWVP) of the Northern
            Marianas Islands Department of Public Health provides outreach,
            health screening, and education. WWVP addresses noncommunicable
            diseases (diabetes, mellitus, hypertension, cardiovascular
            disease, and cervical cancer) in addition to tobacco use
            assessment and cessation referral. It addresses physical
            activity promotion through a partnership with a faith-based
            organization and other community organizations.
      --BodyWorks.--Another OWH program, BodyWorks, is designed to help
            parents and caregivers of adolescents improve family eating and
            activity habits. The program focuses on parents as role models
            and provides them with hands-on tools to make small, specific
            behavior changes to prevent obesity and help maintain a healthy
            weight. The program uses a train-the-trainer model to
            distribute the Toolkit through community-based organizations,
            State health agencies, nonprofit organizations, health clinics,
            hospitals and healthcare systems. There are approximately 20
            trainers in Hawaii; a list can be found at: http://
            www.womenshealth.gov/BodyWorks/
            find.trainers.statedetail.cfm?state=HI.
         administration for children and families: office of head start
        The Office of Head Start provides grants to various entities
    including schools, tribes, and nonprofit and for-profit agencies to
    provide comprehensive child development services to economically
    disadvantaged children and family. A major focus of services to
    enrolled children and their families is towards improving health
    outcomes through the provision of educational, nutritional, and health
    services. These primary and secondary prevention services are making a
    major impact on improving health outcomes for those Native Hawaiian
    children and families that are currently served under existing Head
    Start grants. Hawaii is served under region 9. The most recent
    statewide data (Source: 2008 OHS Program Report Information) shows that
    Head Start funds a total of 7 grantees, and 21 percent of the Hawaii
    State HS/EHS children served are Native Hawaiian or other Pacific
    Islander ethnicity. This includes 1,588 for Head Start and 377 for
    Early Head Start.
        Head Start's goals include prevention and reduction of childhood
    overweight and obesity, to reduce the incidence of Type 2 Diabetes
    Mellitus. Obesity is a major risk factor for the development of Type 2
    Diabetes Mellitus. The Office of Head Start is conducting a major
    initiative to prevent and reduce childhood obesity, through a program
    titled ``I Am Moving, I Am Learning''. I Am Moving, I Am Learning
    introduces multidisciplinary teams from local Head Start programs to
    the science of obesity prevention, and arms them with state-of-the-art
    resources and best practices for addressing the growing child obesity
    epidemic in an intentional and purposeful manner.
        Head Start also works to prevent and reduce tobacco smoke exposure.
    The Family and Child Experiences Survey study shows that 45 percent of
    Head Start families smoke and 56 percent of Early Head Start families
    smoke. The Office of Head Start and the Indoor Environments Division of
    the U.S. Environmental Protection Agency are partnering to improve the
    overall health of Head Start children. The partnership aims to reduce
    young children's exposure to secondhand smoke and other asthma
    triggers. The goal of the partnership is not to get parents to stop
    smoking. Rather, the purpose of the toolkit is for Head Start staff to
    use the information as a means to educate parents of the many ways to
    enhance their children's health.
         hhs grants provided to organizations serving native hawaiians
        Administration for Children and Families/Administration for Native
    Americans (ACF/ANA)
        Grantee.--Wai'anae Coast Comprehensive Health Center
        Project Title.--Strengthening Families and Promoting Healthy
    Lifestyle
        Project Funding.--$542,064 (includes anticipated continuation
    awards)
        Total ANA Funding.--$2,014,024
        The Wai'anae community is located on the western side of the island
    of Oahu. Its population grew from 3,000 people in 1950 to 45,000 people
    today, of which 40 percent are Native Hawaiian and 45 percent are under
    the age of 25. The Wai'anae coast is an economically distressed
    community ranked highest on the island for: households receiving
    financial aid and food stamps; households under the poverty line; and
    rates of unemployment, infant mortality and teen births. Health issues
    are a major concern in the community as Native Hawaiians have the
    highest prevalence of obesity and diabetes in the State. Additionally,
    an estimated 1,000 homeless residents, most of whom are Native
    Hawaiian, live on the Wai'anae coast.
        The Wai'anae Coast Comprehensive Health Center is a Federal Public
    Health Service Community Health Center 330(e) grantee that has served
    the community for the past 32 years. During this time, the Center has
    developed a unique model of healthcare that addresses individual,
    family and community needs through a combination of traditional and
    modern practices.
        The Strengthening Families and Promoting Healthy Lifestyle Project
    developed a healthy culinary training program to promote activities to
    retain and re-establish traditional foods in the family diet. There
    were 939 youth involved in this project. Many Native Hawaiian at-risk
    youth demonstrated improved self-esteem and began integrating the
    traditional culture into their daily lives. For the youth participants
    that were overweight, the project health activities provided a
    comforting and encouraging atmosphere to lose weight. The youth were
    involved in outreach activities like designing the ``KidFit T-Shirt''
    and creating the Health Center's video public service announcements.
        For the involved families, the project promoted bonding through
    exercise, healthy eating and the revitalization of Kumu Ohana, all of
    which contribute to healthy lifestyles that can prevent diabetes and
    cancer among Native Hawaiians. In addition, the project created 15 jobs
    and leveraged resources were more than $100,000.
        Grantee.--Wai'anae Community Re-Development Corporation
        Project Title.--The Center for Organic Agriculture and
    Sustainability
        Project Funding.--$1,152,476 (includes anticipated continuation
    awards)
        Total ANA Funding.--$1,790,037
        According to the project leaders at Ma'o Organic Farms, Wai`anae
    youth struggle to achieve their socio-economic goals. The statistics
    suggest a bleak future for many Native Hawaiian youth with the State's
    highest rates of teen pregnancy, school suspensions, incidents of
    substance abuse, and juvenile arrests. In addition, Wai`anae is
    recognized as the most food insecure region of Hawaii with Native
    Hawaiians having the highest rates of preventable disease including
    diabetes, heart disease and some cancers. Despite these statistics,
    Wai`anae residents still maintain a rural vision, a willingness to
    perpetuate our community's ``country'' values and to offer hope and
    validation to our `opio of their personal and cultural identities.
        The Center for Organic Agriculture and Sustainability, at Ma'o
    Organic Farms, will positively impact the well-being of Wai'anae youth
    by promoting healthy lifestyles and decreasing the incidence of
    diabetes. The project will engage Native Hawaiian youth in the
    development of organic agriculture and will provide a foundation for
    economic opportunities for youth participants.
        The 3-year project will provide multi-purpose venue for food
    production that will increase commercial efforts of organic farms and
    develop a working base for social enterprise, organic agriculture and
    sustainability that can be replicated in other communities.
        Grantee.--Waipa Foundation
        Project Title.--Waipa Community Kitchen and Business Incubator
    Project
        Project Funding.--$709,260
        Total ANA Funding.--$867,010
        This is a 3-year project to provide a fully-equipped and certified
    commercial kitchen facility that will allow farmers, families, and
    community members to process crops and grow small businesses. The Waipa
    Community Kitchen and Business Incubator will promote a healthy,
    diverse, and sustainable local food economy for the Halele'a-Kilauea
    communities.
        Grantee.--University of Hawaii and Manoa Center (Collaborative
    Project)
        Project Title.--The Hawaii Demonstration to Maintain Independence
    and Employment Project
        Project Funding.--$1,539,002
        The Hawaii Demonstration to Maintain Independence and Employment
    project is a joint endeavor between the Hawaii State Department of
    Human Services, the University of Hawaii at Manoa Center on Disability
    Studies, the Hawaii State Department of Health (DOH), and the Hawaii
    Business Health Council.
        These agencies will engage in a collaborative effort with public
    and private employers, employee groups, and their healthcare providers
    in a comprehensive community-based effort to assist individuals who are
    at high risk of becoming disabled/unemployed as a result of diabetes.
        The partnership enlists promising and emerging practices to
    identify and support persons, ages 18 through 60 years old, with
    potentially disabling and medically determinable physical impairments
    as a result of diabetes.
        Substance Abuse and Mental Health Services Administration (SAMHSA)
        Grantee.--Hawaii Families as Allies--Aiea, HI
        Program.--Statewide Family Networks SM057920
        Congressional District.--HI-01
        Fiscal Year 2008 Funding.--$70,000
        Project Period.--9/30/2007-9/29/2010
        The Hawaii Statewide Transformation and Empowerment Project (STEP)
    will conduct training, technical assistance, and networking activities
    aimed at substantially increasing the involvement of children and youth
    with emotional, behavioral or mental disorders and their families in
    all levels of Hawaii's system of care. Family members will be supported
    so that they will be able to develop and implement a legislative
    advocacy action plan. STEP will also involve key child-serving
    agencies, including those responsible for child welfare and juvenile
    justice, in an initiative to increase their awareness of and adherence
    to the CASSP values and principles. Another set of activities will
    focus on youth leadership development, focusing on developing and
    implementing a legislative advocacy initiative. HFAA Parent Partners
    will also provide peer supports and mentoring for youth and families in
    their home communities throughout Hawaii.
        Grantee.--Hawaii State Department of Health--Honolulu, HI
        Program.--Child Mental Health Initiative SM057063
        Congressional District.--HI-01
        Fiscal Year 2008 Funding.--$1,257,281
        Project Period.--9/30/2005-9/29/2011
        Project Ho'omohala (meaning in Hawaiian, ``evolving toward
    maturity'') will develop a system of care to meet transitional needs of
    youth with emotional and/or behavioral challenges, ages 15-21 in the
    Kalihi-Palama community. Culturally and linguistically appropriate
    services will utilize the transition to independence process. Families
    and youth will be active partners in the governing structure and
    evaluation process. The goal of this project is to implement a system
    of care encompassing the transition to independence process for youth
    with emotional or behavioral challenges between the ages of 15-21,
    living in the Kalihi-Palama Community. This goal will be implemented
    through the following actions: (1) establish a Youth Community Center;
    (2) train and assign transition specialists to each youth; (3) develop
    a comprehensive life-skills program; (4) create a range of supportive
    services (e.g., vocational, healthcare); and (5) develop peer mentoring
    services. The applicant is the Hawai'i Department of Health on behalf
    of the governor. Daily management of the grant will be contracted
    through the Center on Disability Studies at the University of Hawai'i.
    The Youth Community Center will be operated by the Susannah Wesley
    Community Center. Wai Aka will provide the young adult support
    services; families and youth will guide the development,
    implementation, and evaluation of this project.
        Grantee.--Hawaii State Department of Health--Honolulu, HI
        Program.--State Data Infrastructure Grants SM058093
        Congressional District.--HI-01
        Fiscal Year 2008 Funding.--$156,000
        Project Period.--9/30/2007-09/29/2010
        During the project period, AMHD will focus on technical
    implementation of the URS measures, verification of data quality, and
    increased distribution of reports to its Purchase of Service Provider
    network. CAMHD will implement the remaining URS developmental measures,
    but emphasizes building capacity in the knowledge, skills, and
    abilities of personnel to define and distribute customized reports and
    to participate more fully in the DIG network. Upon completion AMHD and
    CAMHD should report on all URS measures, increase distribution of
    system information to stakeholders including State council, increase
    integration of the available information into planning and decision
    making.
        Grantee.--Hawaii State Department of Health--Honolulu, HI
        Program.--Mental Health Transformation State Incentive Grants
    SM057457
        Congressional District.--HI-01
        Fiscal Year 2008 Funding.--$2,190,500
        Project Period.--9/30/2006-9/29/2011
        The goal of this mental health systems transformation project is to
    create a sustainable, fully integrated, comprehensive statewide mental
    health plan and to implement a system-wide transformation process over
    the course of a 5-year period. Staffing for this grant can be
    conceptualized as a model of concentric circles whereby the
    transformation work group is at the center surrounded by mental health
    stakeholders coming together in different partnerships to breathe life
    into the transformation. The next ring supporting these activities is a
    technical assistance group and project evaluation team comprised of
    grant-funded staff and in-kind University of Hawaii staff who will
    assist the transformation work group and stakeholders in tasks such as
    planning, implementation, program evaluation and workforce development.
    Finally, the outer ring of the model is the community-at-large whose
    acceptance of mental health as an integral part of overall well being
    is required to bring about full transformation of the system. Hawaii,
    because of its diversity, is in a unique position to develop effective
    models of service delivery and care that address the needs of the
    growing multi-cultural population across the country. Hawaii is
    committed to seizing the opportunity created by national and State
    strengths and resources; directing and focusing the efforts of all
    sectors to address priority mental health needs; building on successes
    to move past an era of Federal court mandates; and realizing the vision
    of quality mental healthcare across all of Hawaii's communities for the
    entire population.
        Grantee.--United Self-Help--Honolulu, HI
        Program.--Statewide Consumer Network SM056346
        Congressional District.--HI-01
        Fiscal Year 2008 Funding.--$70,000
        Project Period.--9/30/2004-9/29/2010
        Bridging Islands will foster and sustain consumer networks within
    each neighbor island, collaborate with existing networks and strengthen
    pee mentors. Each goal will address county based needs within each area
    with specific outcomes. The process will increase State capacity to
    support effective mental health services while strengthening peer
    mentors and sustaining neighbor island consumer network development.
    Collectively, the county and consumers will evaluate lessons learned
    and incorporate recommendations into the next iteration of
    transformation activities.
        Grantee.--Hawaii State Department of Health--Honolulu, HI
        Program.--Youth Suicide Prevention and Early Intervention--
    Cooperative Agreement State-Sponsored SM058397
        Congressional District.--HI-01
        Fiscal Year 2008 Funding.--$500,000
        Project Period.--9/30/2008-9/29/2011
        The Injury Prevention and Control Section (IPCS) of the DOH is
    proposing to implement the Hawaii Gatekeeper Training Initiative (HGTI)
    to reduce completed and attempted suicides among youth ages 10-24. This
    will be accomplished through training adult gatekeepers in key agencies
    to recognize and respond to youth who are at risk for suicide. This
    will also increase youth access to trained gatekeepers in Hawaii. The
    HGTI will use three training curricula: Applied Suicide Intervention
    Skills Training (adults), SafeTALK (police officers), and Signs of
    Suicide (youth). IPCS will leverage the grant resources by
    incorporating gatekeeper training in three systems that already impact
    significant numbers of youth in both school and community settings.
    These agencies and their programs include: Department of Education
    (Peer Education Program), and School-Based Behavioral Health), the
    Department of Health Alcohol and Drug Abuse Division (agencies
    contracted to provide treatment services in their Adolescent Substance
    Outpatient School-Based Treatment Program), and prevention services in
    their Youth Substance Prevention Partnerships Initiative), and the
    Honolulu Police Department (Emergency Psychological Services/Jail
    Diversion Program). The HGTI will accomplish two goals: (1) enhance
    State level infrastructure for youth suicide prevention efforts, and
    (2) enhance youth suicide prevention efforts in three systems: Public
    School, Alcohol/Substance Abuse Treatment and Prevention, and Law
    Enforcement.
        Center for Substance Abuse Prevention (CSAP)
        Grantee.--Parents and Children Together--Honolulu, HI
        Program.--Drug Free Communities SP012968
        Congressional District.--HI-01
        Fiscal Year 2008 Funding.--$100,000
        Project Period.--9/30/2005-9/29/2010
        The grantee will: (1) reduce substance abuse among youth and over
    time, among adults by addressing factors in the community that increase
    the risk of substance abuse and promote factors to minimize the risk of
    substance abuse; (2) establish and strengthen citizen participation and
    collaboration among communities, nonprofit agencies, and Federal,
    State, local, and tribal governments to support community efforts to
    deliver effective substance use prevention strategies for youth; (3)
    use the Strategic Prevention Framework of evidence based prevention
    strategies to assess needs, build capacity, plan, implement and
    evaluate community prevention initiatives; and (4) assess and report on
    the effectiveness of community prevention initiatives to reduce age of
    onset of any drug use, frequency of use in the past 30 days, increased
    perception of risk or harm, and increased perception of disapproval of
    use by peers and adults.
        Grantee.--Waipahu Community Association--Waipahu, HI
        Program.--Drug Free Communities SP011543
        Congressional District.--HI-01
        Fiscal Year 2008 Funding.--$100,000
        Project Period.--9/30/2005-9/29/2009
        The grantee will: (1) reduce substance abuse among youth and, over
    time, among adults by addressing the factors in a community that
    increase the risk of substance abuse and promoting the factors that
    minimize the risk of substance abuse; and (2) establish and strengthen
    community anti-drug coalitions.
        Grantee.--Coalition For A Drug-Free Hawaii--Honolulu, HI
        Program.--Drug Free Communities SP014887
        Congressional District.--HI-01
        Fiscal Year 2008 Funding.--$125,000
        Project Period.--9/30/2008-9/29/2013
        The grantee will: (1) reduce substance abuse among youth and over
    time, among adults by addressing factors in the community that increase
    the risk of substance abuse and promote factors to minimize the risk of
    substance abuse; (2) establish and strengthen citizen participation and
    collaboration among communities, nonprofit agencies, and Federal,
    State, local, and tribal governments to support community efforts to
    deliver effective substance use prevention strategies for youth; (3)
    use the Strategic Prevention Framework of evidence based prevention
    strategies to assess needs, build capacity, plan, implement and
    evaluate community prevention initiatives; and (4) assess and report on
    the effectiveness of community prevention initiatives to reduce age of
    onset of any drug use, frequency of use in the past 30 days, increased
    perception of risk or harm, and increased perception of disapproval of
    use by peers and adults.
        Grantee.--Coalition For A Drug-Free Hawaii--Honolulu, HI
        Program.--Sober Truth on Preventing Underage Drinking Act Grants
    SP015489
        Congressional District.--HI-01
        Fiscal Year 2008 Funding.--$50,000
        Project Period.--9/30/2008-9/29/2012
        The purpose of the Sober Truth on Preventing Underage Drinking
    (STOP) Act grant program is to prevent and reduce alcohol use among
    youth in communities throughout the United States. The STOP Act grant
    program will encourage existing local community coalitions to develop,
    assess, and implement effective strategies to prevent and reduce
    underage drinking. Strategies may include: changing local attitudes and
    norms, and re-evaluating existing laws and policies. (1) Grantee must
    participate in national evaluation activities of the STOP grant
    program. (2) STOP Grantees must use the Strategic Prevention Framework
    (SPF), a five-step evidence based process for community planning and
    decision-making. The five step process includes: needs assessment,
    capacity building, planning, implementation and evaluation. (3) STOP
    grantees must plan and implement a comprehensive approach inclusive of
    multiple strategies as emphasized in the 2007 Surgeon General's Call to
    Action to prevent and Reduce Underage Drinking located online at:
    http://www.surgeongeneral.gov/topics/underagedrinking/call--to--
    action.pdf Emphasis should be given to environmental strategies that
    incorporate prevention efforts aimed at changing or influencing
    community conditions, standards, institutions, structures, systems and
    policies. In addition, grantees must select strategies that lead to
    long term outcomes. (4) STOP grantees must enhance, not supplant,
    effective local community initiatives for preventing and reducing
    alcohol use among youth. For current Drug Free Community grantees, STOP
    ACT foods can not be used to supplant or replace activities that are
    presently being supported by Drug Free Community funds, and, separate
    DFC and STOP ACT accounting systems must be maintained for the purposes
    of reporting.
        Grantee.--Kulia Na Mamo--Honolulu, HI
        Program.--HIV/Strategic Prevention Framework SP013382
        Congressional District.--HI-01
        Fiscal Year 2008 Funding.--$254,320
        Project Period.--9/30/2005-9/29/2010
        The project targets Asian and Pacific Islander male-to-female
    transgender and men who have sex with men, age 27 and older. Many of
    the former are ex-incarcerated, and both groups, which make up the Mahu
    (two spirits) community in Hawaii, are minority populations at highest
    risk for HIV (i.e., of all API diagnosed with AIDS, over 65 percent are
    MSM, which includes transgender). From our own surveys of over 100
    transgender clients, more than 60 percent are ex-inmates, 54 percent
    are sex industry workers and more than 30 percent are crystal meth
    users. 50 percent of the participants will be re-entry. Interventions
    will be provided to approximately 150 participants a year. The project
    is divided into two parts: (1) Capacity Building.--The application will
    spend the first 6 to 9 months of the first year establishing a
    workgroup or task force that will conduct a community needs assessment.
    The task force will be made up of the following agencies: Department of
    Health STD/AIDS Prevention Branch; Department of Health Disease Control
    and Outbreak Division; Life Foundation, an AIDS service organization;
    Drug Addiction Services of Hawaii, Inc.; Coalition for a Drug-Free
    Hawaii, a prevention agency; Hina Mauka, a treatment/prevention agency;
    Department of Public Safety; Hawaii Cares--the coalition of Ryan White
    providers; and other agencies. The needs assessment will be the basis
    for a strategic plan to be implemented after approval from SAMHSA.
    During this initial period Kulia Na Mamo will develop memoranda of
    agreement with treatment agencies, the Department of Public Safety, and
    others with which to establish linkages to care. Kulia will attend
    meetings of the HIV Community Planning Group, work with the Jade Ribbon
    Campaign for hepatitis B testing, and coordinate activities related to
    hepatitis C with the hepatitis C coordinator at the Department of
    Health STD/AIDS Prevention Branch. (2) Implementation, Monitoring, and
    Evaluation.--The proposal follows interventions endorsed by the CDC
    and/or SAMHSA: Prevention.
        Grantee.--Hawaii State Office of the Governor--Kaplei, HI
        Program.--Strategic Prevention Framework State Incentive Grants
    SP013944
        Congressional District.--HI-01
        Fiscal Year 2008 Funding.--$2,093,000
        Project Period.--9/30/2006-9/29/2011
        The purpose of Hawaii's SPF State Incentive Grant (SIG) is to
    improve the quality of life of our citizens by preventing and reducing
    the abuse and dependence on alcohol and other drugs among people of all
    ages. The SPF SIG will enable Hawaii to (a) support a coordinated and
    comprehensive approach to substance abuse prevention; (b) ensure that
    prevention is the first line of defense against illegal drug use and
    underage drinking; (c) establish effective alcohol and other substance
    abuse prevention efforts that are evidence-based, culturally
    appropriate, and long term; and (d) minimize duplicative efforts among
    partnering agencies, while promoting coordination and identifying gaps
    in data and services.
        Grantee.--Five Mountains Hawaii--Kamuela, HI
        Program.--Drug Free Communities SP012310
        Congressional District.--HI-02
        Fiscal Year 2008 Funding.--$125,000
        Project Period.--9/30/2005-9/29/2013
        The grantee will: (1) reduce substance abuse among youth and, over
    time, among adults by addressing the factors in a community that
    increase the risk of substance abuse and promoting the factors that
    minimize the risk of substance abuse; and (2) establish and strengthen
    community anti-drug coalitions.
        Grantee.--Hamakua Health Center--Honokaa, HI
        Program.--CSAP 2008 EARMARKS SP014596
        Congressional District.--HI-02
        Fiscal Year 2008 Funding.--$95,305
        Project Period.--9/01/2008-8/31/2009
        This project is designed to improve access for the low-income and
    uninsured population and improve the coordination of care between
    agencies in each of the Health Center service areas, resulting in
    greater accessibility to support services and increased referral
    follow-through for patients with risk for and active substance abuse.
        Center for Substance Abuse Treatment
        Grantee.--Hawaii State Department of Health--Honolulu, HI
        Program.--Access to Recovery TI019437
        Congressional District.--HI-01
        Fiscal Year 2008 Funding.--$2,750,000
        Project Period.--9/30/2007-9/29/2010
        The Hawaii Access to Recovery (HI-ATR) program targets the adult
    population of child welfare families for the Hawaii Island of Oahu
    (City and County of Honolulu). ``Ice'' is the major factor behind
    Hawaii's explosion of child protection cases, in which Native Hawaiians
    represent more than 50 percent of Child Protective Services cases and
    other Asian-Pacific Islanders are also overrepresented. Hawaii is a
    unique State with (1) the greatest proportions of methamphetamine or
    ``ice'' abuse in the Nation, (2) inadequate and fragmented treatment
    resources and significantly limited recovery support services. HI-ATR
    Project will introduce a system of vouchers managed electronically
    through a 42 CFR, Part 2 and HIPAA-compliant web-based information
    technology (IT) system to improve access to treatment and, subsequent
    to adequate assessment and referral to an appropriate level of care,
    genuine independent client choice of service providers, including faith
    and community-based organizations (FCBOs), especially those that have
    not previously received public funding. This project will not only
    provide the critically needed additional capacity to address Hawaii's
    ice epidemic but will also contribute significantly to strengthening
    existing families and healing and reunifying shattered Asian/Pacific
    Island families, thus ensuring the preservation of the unique heritage
    and traditions of Hawaii's peoples.
                                 practitioners
        Question. Given the need to create practice incentives for
    practitioners that are aligned with the health reform legislation being
    proposed (such as cost-effective practice, adoption of quality
    measures, and use of practice guidelines), what medical legal
    protections can be extended to practitioners on a Federal level such
    that the practice of defensive medicine is eliminated?
        Answer. The President has stated that he understands that some
    doctors feel that they are looking over their shoulders out of fear of
    lawsuits and often order more tests and treatment to avoid being
    legally vulnerable. He does not advocate caps on malpractice awards,
    which could be unfair to people who've been wrongfully harmed, but he
    does think we should explore a range of ideas to put patients first
    while letting doctors focus on practicing medicine. There have been a
    number of proposals offered in recent years to reduce lawsuits and
    promote patient safety, from plans to expand the use of ``Sorry Works''
    systems (early disclosure and apology-based mediation) as then-Senator
    Obama introduced in 2005, to proposals to encourage broader use of
    evidence-based guidelines as Senator Wyden and others have supported.
    There are many ideas out there and the President and I want to work
    with you.
        Question. Given the shortage of rural practitioners across America
    and the limitations associated with recruitment and retention of
    practitioners to rural Hawaii, what incentives can be established to
    encourage rural training of practitioners, including needed
    specialists?
        Answer. Effective health action requires an adequately staffed,
    highly skilled, diverse and interdisciplinary workforce prepared to
    address health challenges of the 21st century. In HRSA, the budget
    expands loan repayment and scholarship programs for physicians, nurses,
    and dentists who are committed to practicing in medically underserved
    areas. Additionally, funding will enhance the capacity of nursing
    schools, increase access to oral healthcare through dental workforce
    development grants, target minority and low-income students, and place
    an increased emphasis on ensuring that America's senior population gets
    the care and treatment it needs.
        The administration also provided additional funds for the Indian
    Health Service (IHS) to cover the rising cost of tuition impacting
    scholarship and loan repayment programs. These programs help IHS
    compete with other public and private sector employers and bring needed
    healthcare professionals to remote, rural reservations. In addition,
    IHS provides grants to universities to train American Indians and
    Alaska Natives to return to their communities as healthcare
    professionals. We believe these programs will help ease the shortage of
    rural practitioners over time.
                                     ______

                  Questions Submitted by Senator Patty Murray
                              healthcare workforce
        Question. One area of concern that I believe must be addressed is
    the shortage of healthcare providers. And as the baby boomers retire,
    the problem is only going to get worse.
        I have had a number of roundtables throughout my home State of
    Washington on this issue. And I know that what we're seeing in
    Washington State is similar to what is going on across the country. The
    shortage of doctors, nurses, and other healthcare providers is one of
    the most serious workforce challenges our country faces.
        And as we are working on healthcare reform, I believe it is
    important to keep in mind that affordable care will not be possible
    without access to a healthcare provider. In addition, this workforce
    shortage is only going to get worse as we move to cover more people.
        What do you see as our best tools to address this problem within
    the regular appropriations process?
        Answer. The National Health Service Corps provides a venue to
    incentivize more primary care providers across the spectrum (including
    dentistry, nursing, and mental health) to serve in underserved areas.
    This program can be targeted towards people at the end of their
    education, to address short-term as well as long-term workforce needs.
    Expanding nurse faculty loan programs will address a critical
    bottleneck in the education of new nurses to address the current and
    looming nursing shortage. Providing additional funds for scholarships
    and loan repayment programs for students--including those targeted to
    improve diversity--can also have a dramatic impact on ensuring an
    effective workforce.
        The fiscal year 2010 request includes over $1 billion supporting a
    wide range of programs to strengthen and support our Nation's
    healthcare workforce. These investments will expand loan repayment and
    scholarship programs for physicians, nurses, and dentists who are
    committed to practicing in medically underserved areas. Additionally,
    this funding will enhance the capacity of nursing schools and increase
    access to oral healthcare through dental workforce development grants.
        Question. How do you think we can address this problem within
    healthcare reform?
        Answer. We can and should build on existing workforce programs such
    as the National Health Service Corps and title VII and title VIII.
    These programs need to be modernized to better address a changing
    healthcare environment. We should also encourage innovation in
    telemedicine, health IT, and other avenues to improve practice
    environments which will enhance workforce productivity and retention.
                                 home visiting
        Question. I am so pleased that President Obama and your agency are
    focusing on Home Visiting as an effective program to ensure that
    children and families receive the supports and information they need
    for healthy development, child abuse prevention, safety, and
    preparation for education. As you know, I introduced the Education
    Begins at Home Act with Senators Clinton and Bond earlier this year,
    which focuses on promoting high-quality, effective home visiting
    programs that improve the health, development, and school readiness of
    children ages 0 to 5.
        I think it's necessary to highlight a few key components to any
    effective home visiting program to ensure the best outcomes for
    children across the country. It is critical that any program is
    evidence-based, which I know is important you and the President as
    well. Another important component is providing support not only for
    health outcomes, but also well being and school readiness, in a
    continuum of home visiting care. When all of these outcomes are met,
    home visiting can reduce the need for special education services, help
    families raise their monthly earnings, reduce child abuse, prepare
    children to succeed in pre-K or kindergarten, and assist with stronger
    birth outcomes, among many other benefits.
        Do I have your commitment to work towards a model that provides
    significant support for the continuum of home visiting programs and
    models, as long as they are evidence-based, in order to meet the varied
    needs of young children and their families across the country?
        Answer. Yes, the Home Visitation initiative will give priority to
    models that have been rigorously evaluated and shown to have positive
    effects on critical outcomes for families and children. Additional
    funds will support promising programs, such as programs based on models
    with some research evidence of effectiveness and adaptations of
    previously evaluated programs.
                        title x family planning program
        Question. In a report released last week by the National Academy of
    Sciences Institute of Medicine, family planning was described as ``one
    of the most significant public health achievements of the 20th
    century.'' The report goes on to say that family planning has resulted
    in improvements in health, economic and social well-being.
        The Institute's study also cites that ``funding for the title X
    (Ten) Program has not kept pace with a number of factors including:
    inflation; increased costs of contraceptives, great numbers of people
    seeking services; or rising insurance costs.''
        Do you agree with the assessment that family planning funding has
    not kept pace with these factors?
        Answer. The title X program has been able to maintain access to
    services for millions of individuals who need family planning services
    each year through maximizing the resources provided in the
    appropriations each year. Through the program's training authority,
    training has been provided to title X administrators and clinical
    providers to encourage the most efficient utilization of resources
    while maintaining quality. In addition, title X providers have been
    encouraged to use the 340B Drug Pricing Program, cooperative purchasing
    programs, and other cost-savings mechanisms to cut costs where
    possible.
        Question. Do you think that a significant increase in funding for
    the title X program will help serve the ever increasing number of
    American families who are unable to afford the most basic of healthcare
    services?
        Answer. The fiscal year 2010 budget provides an increase that would
    enable the title X program to serve a greater number of low-income
    individuals who are currently not receiving services. Currently, 4 in
    10 poor women of reproductive age have no insurance coverage, public or
    private. The Title X Family Planning Program requires that services be
    provided to all who want and need them, with a priority for services to
    individuals from low-income families. Title X-funded centers are an
    important source of preventive healthcare to nearly 5 million women
    each year, more than 90 percent of whom have family incomes at or below
    200 percent of the Federal poverty level. At least 64 percent of those
    served by title X centers have no insurance coverage for primary
    healthcare, public or private. According to the most recent National
    Survey of Family Growth data, a majority of women who obtain care at a
    family planning center consider it their usual or primary source of
    healthcare. It is estimated that only 54 percent of women in need of
    publicly subsidized contraception received those services in 2006, with
    title X providing services to half (27 percent) of these women.
        In addition to the contraceptive services provided under the title
    X program, title X-funded family planning centers provide a number of
    related preventive health services that millions of poor and uninsured
    individuals would likely not otherwise receive. For instance, in 2007,
    title X-funded health centers provided almost 2.5 million Pap tests;
    2.4 million breast exams; 5.4 million tests for sexual transmitted
    diseases that if left untreated, may lead to infertility; and, 764,126
    confidential HIV tests. In addition, it is estimated that nearly
    970,000 unintended pregnancies were averted through the services
    provided by title X-funded centers in 2007.
             u.s. domestic refugee program and the economic crisis
        Question. Historically, the United States has been the world leader
    in providing protection and assistance to refugees both internationally
    through humanitarian assistance and domestically by resettling refugees
    to the United States. Unfortunately, the resettlement program now finds
    itself on the brink of crisis.
        The Office of Refugee Resettlement (ORR) within the Department of
    Health and Human Services was established in 1980 to assist refugees
    admitted by the United States in obtaining economic self-sufficiency.
    Since then, ORR's mission has grown to include assisting numerous other
    vulnerable populations in the United States, among them trafficking
    victims, torture victims, Cuban/Haitian Entrants, Indochinese Parolees,
    Iraqi and Afghan Special Immigrants, and unaccompanied alien children.
    Unfortunately, ORR's budget has not kept up with its growing mission,
    the changing characteristics of the populations it now serves, and the
    costs and needs of resettling today's refugees. Coupled with chronic
    under funding, the challenges connected to the current economic crisis
    have placed the resettlement program in peril.
        Even before the current economic recession, resettlement agencies
    have been struggling to meet the needs of refugees, and a number of
    agencies had to close down offices across United States. Now refugees
    are commonly experiencing great difficulty finding work and paying rent
    and other basic household needs. Agencies that have relied on private
    funding, donations and the help of our communities to overcome the
    insufficient funding are struggling to secure resources in the current
    environment. The situation is critical; the resettlement program needs
    immediate reform in key areas to maintain the success it has achieved
    in the past and to match our international commitment to provide
    protection to refugees.
        How is ORR planning to respond to the consequences of the economic
    crisis on the resettlement program and ensure adequate assistance to
    refugees and other vulnerable populations while they work toward
    integration and self-sufficiency? What steps will ORR take in the
    future to better respond to emergency situations?
        Answer. ORR provides a host of supports to refugees to assist them
    with achieving economic self-sufficiency and integration, including
    cash and medical assistance, case management, and employment services.
    The current economic conditions have made it more difficult for
    refugees to gain employment quickly, even for those in the Matching
    Grant program, which historically has been the most successful method
    for placing refugees into employment quickly. As a result, refugees and
    other eligible populations are accessing cash and medical assistance
    for longer periods of time, often for the full 8 months for which they
    are currently eligible. The number of refugees also is on the rise,
    and, for the first time since 2001, the number of arrivals appears to
    be approaching the refugee ceiling set by the State Department. For
    these reasons, the fiscal year 2010 budget request includes $337
    million for refugee transitional and medical services, $55 million more
    than the amount appropriated in fiscal year 2009. ORR will closely
    monitor arrivals and benefit access, and provide updated cost estimates
    to Congress as necessary. The Administration is also keenly interested
    in examining ways to improve refugee resettlement programs, especially
    in light of the current economic crisis.
                          emergency housing assistance
        Question. The economic crisis is negatively impacting refugees
    across the country, challenging their successful integration into our
    communities and making homelessness a real threat to many refugee
    families. Due to rising living costs and a shortage of jobs, newly
    arriving refugees are finding it increasingly difficult to secure and
    maintain employment and housing. As a result, some refugee families are
    not able to find jobs and meet the cost of rent, and are thus facing
    eviction and homelessness. Several recent news stories illustrate the
    challenges refugees are facing with housing and homelessness across the
    country.
        A number of federally funded programs administered by local refugee
    resettlement agencies assist refugees in securing employment and
    housing. These programs have been highly effective in helping refugees
    achieve early self-sufficiency through employment. However, refugees
    are only eligible for benefits and services for a maximum of the first
    8 months in the United States. In the current economic climate it can
    take refugees longer than 8 months to secure employment which would
    enable them to afford basic housing. Additionally, many of those
    refugees who have been able to secure employment have been recently
    laid off and have lost their source of income. In most of these cases
    refugees have not worked long enough to qualify for unemployment
    benefits.
        What steps will you take to address the housing needs of resettled
    refugees and other vulnerable populations served by the ORR to prevent
    evictions and homelessness for these populations?
        Answer. The President's budget request is intended to address many
    refugee needs. With respect to risk of homelessness, refugees can
    access a variety of homelessness prevention and assistance programs
    through the U.S. Department of Housing and Urban Development (HUD) or
    State or county housing programs. HHS Refugee Resettlement funds have
    not been targeted to homeless services, beyond the provision of cash
    assistance and some limited use of social services funds.
        Question. How are you planning to address the housing needs of
    refugees that have been in the United States for more than 8 months,
    are not longer receiving cash assistance and have not achieve self-
    sufficiency?
        Answer. The President's budget request is intended to address many
    refugee needs. With respect to risk of homelessness, refugees can
    access a variety of homelessness prevention and assistance programs
    through the U.S. Department of Housing and Urban Development or State
    or county housing programs. HHS Refugee Resettlement funds have not
    been targeted to homeless services, beyond the provision of cash
    assistance and some limited use of social services funds.
        Question. The cash assistance refugees receive is determined by
    welfare rates in the States they reside in. In almost all cases (some
    stats would be nice), the level of assistance is below poverty line and
    does not even cover rent. How will you ensure that refugees are not
    resettled into an immediate crisis situation, critically dependent on
    securing a job in order to stay in their homes?
        Answer. Refugee populations are exempted from any bars restricting
    legal permanent resident aliens from accessing public benefits such as
    TANF, Medicaid, and SSI, and may therefore access a number of services
    apart from cash assistance provided by ORR, if they are otherwise
    eligible. In addition, refugees may access services provided through
    ORR's Refugee Social Services and Targeted Assistance funds, including
    adjustment services, English language instruction, interpretation and
    translation services, day care for children, citizenship and
    naturalization services, etc. The goal of these services is to maximize
    refugees' prospects for self-sufficiency.
        Question. Looking forward to the future, how ORR will ensure that
    refugees and other vulnerable people it serves have a safety net strong
    enough to prevent them from losing their homes while they look to
    secure employment?
        Answer. Refugees can access a variety of homelessness prevention
    and assistance programs through HUD or State and county housing
    programs. They are also generally eligible for public benefits such as
    TANF, Medicaid, and SSI. ORR's mandate is to provide services such as
    cash assistance, medical assistance, case management, and employment
    services. The goal of these services is to maximize refugees' prospects
    for self-sufficiency, which will hopefully mitigate any risk of acute
    problems such as homelessness.
                 assisting refugees to achieve self-sufficiency
        Question. The resettlement program has as a main objective to
    assist refugees to obtain self sufficiency in a short period of time.
    The economic crisis has made it more difficult for refugees to achieve
    this goal. While most refugees have typically found employment quickly,
    the worsening economy has made this process lengthier and more
    difficult.
        The current job market makes programs that provide employment
    services all the more critical. One of these programs is the Voluntary
    Agency Matching Grant program. This program enables refugees and other
    eligible persons to become self-sufficient within 4 to 6 months from
    the date of their arrival in the United States without resorting to
    Federal and State welfare programs. The program leverages public funds
    with private donations at a 2:1 ratio, requiring private voluntary
    agencies to provide one dollar of private, nongovernmental resources
    for every $2 that the Federal Government contributes. Nearly 80 percent
    of participants in fiscal year 2008 achieved self-sufficiency. Even
    though the outcomes have been impacted by the current economic crisis,
    Matching Grant continues to be the most successful program helping to
    place refugees in jobs in a 4- to 6-month period.
        Currently the program serves approximately 27,000 individuals, the
    same number of individuals that were served by the program in fiscal
    year 2000. This equals roughly 30 percent of those who could benefit
    from the program. The program has also been expanded to serve not only
    refugees, asylees, Cuban/Haitian entrants, but also Iraqi and Afghan
    Special Immigrant Visas (SIVs) holders and victims of trafficking. The
    Iraqis arriving as refugees or SIVs are in most cases highly educated
    and experienced and would therefore be most appropriately served
    through the Matching Grant (MG) program. Without increased ORR
    resources, additional places in the MG program will not be available.
        As the expression of the public-private partnership the Voluntary
    Match Grant Program is most successful program helping refugees find
    jobs. Are you planning to expand the program by providing more
    resources allowing access for more refugees and other vulnerable
    populations?
        Answer. Under the fiscal year 2010 budget request, the Matching
    Grant program will be funded at the same level as fiscal year 2009.
        Question. Many Iraqis who arrived as SIVs or refugees are highly
    educated and are facing challenges to achieve self-sufficiency and to
    find suitable jobs. In the past the MG program provided better served
    populations with those characteristics. What role do you envision for
    the MG program for highly educates refugees, such as the case of
    Iraqis?
        Answer. The Matching Grant program is indeed ideally suited for
    refugees with good employment prospects, and Iraqi SIVs and refugees
    are generally excellent candidates. To the extent that funded
    enrollment slots are available in the area of resettlement, highly
    educated refugees or SIVs may elect to enroll in the Matching Grant
    Program.
        Question. Highly educated refugees often have to accept the first
    job available to be able to pay for their basic needs. Such a job may
    not be inappropriate for their skill level, which leads to frustration
    on their part and a waste of talent and potential for the American
    society. Do you plan to initiate and fund any programs that would help
    highly educated refugees with years of professional experience secure a
    job appropriate for their skills?
        Answer. While there are no special programs that target skilled
    refugees and no plans to create any expanded assistance to refugee
    professionals, ORR does have an existing grant with a technical
    assistance provider looking at professional recertification issues.
    Most activities for skilled professionals are provided at the
    discretion of local refugee social services providers as part of their
    broader employment services assessment and activities related to each
    Individual Employment Plan. ORR has been working with the Department of
    Labor to identify resources available to refugee professionals through
    the Employment and Training Administration's One Stop Centers.
        Question. The structure of the U.S. resettlement program and its
    emphasis on self-sufficiency is often too rigid to account for
    additional challenges faced by many more vulnerable resettled refugees.
    Many, for example, have been recently widowed or disabled and will be
    much less likely to find employment within the program's limited time
    frame. What changes can be made to account for the special
    circumstances of certain vulnerable refugees to ensure that they are
    able to achieve self-sufficiency in safety and dignity?
        Answer. ORR has no special programs for individuals with
    disabilities or other needs, but ORR providers have broad flexibility
    to work with disabled refugees, and ORR funds may be used to pay for
    these individuals' medical and mental health costs if individuals are
    not eligible for Medicaid. ORR providers also make referrals to (SSI)
    and other benefits and services for refugees who meet disability
    definitions in title XVI of the Social Security Act. Disabled refugees
    who are awaiting adjudication of SSI applications may receive Refugee
    Cash Assistance for up to 8 months while their applications are
    processed. Finally, ORR is taking further steps to improve the self-
    sufficiency prospects of disabled refugees, including early discussions
    with the HHS Office on Disability regarding employment for disabled
    refugees.
                                     ______

                    Questions Submitted by Senator Jack Reed
                   low income home energy assistance program
        Question. As you know, the Low Income Home Energy Assistance
    Program (LIHEAP) was funded at $5.1 billion for the first time in
    fiscal year 2009, providing much needed assistance to millions of
    Americans at a time of economic uncertainty. Although some energy costs
    have temporarily stabilized, the economic standing of millions of
    Americans has worsened. Like funding for food stamps and unemployment
    insurance, LIHEAP provides a significant multiplier effect that is
    important in helping to bring us out of this recession.
        While the President's budget request of $3.2 billion is greater
    than any request made to Congress in the past, it is still far below
    last year's appropriation. The National Energy Assistance Directors'
    Association found that a reduction in LIHEAP funding to $3.2 billion
    could result in more than 1.5 million households being dropped from the
    program, and the average grant for families left in the program being
    cut by $70. While I appreciate the fact that this Administration has
    proposed creating a mandatory contingency fund for LIHEAP when prices
    spike, that funding is dependent on price volatility and will produce
    on $450 million in funding on average per year. We need to have robust
    funding in the base program.
        As you know, the congressional budget resolution matches the
    President's request of $3.2 billion for LIHEAP for fiscal year 2010,
    but would also accommodate an extra $1.9 billion through a
    discretionary cap adjustment that maintain funding at the $5.1 billion
    level. Would you support LIHEAP funding at the $5.1 billion allowed
    under the budget resolution? Will you also work to fully fund this
    program in future budgets?
        Answer. Energy prices are volatile making it difficult to match
    funding to need. Fiscal year 2009 LIHEAP funding ($5.1 billion) was
    provided when energy prices were at their peak (oil at $124 per barrel
    in the second quarter of 2008). Oil prices subsequently declined
    significantly as did Energy Department estimates of average home
    heating costs. The administration proposed the mandatory trigger
    mechanism to address volatility in energy prices. Under this proposal,
    mandatory funding would be provided in response to quarterly energy
    price increases. If oil and gas prices in the fourth quarter of 2009
    exceed peak 2008 prices by just 1.8 percent, total LIHEAP funding of
    $5.1 billion would be provided in fiscal year 2010 through a
    combination of the trigger ($1.9 billion) and the discretionary budget
    request ($3.2 billion).
                                 immunizations
        Question. Immunizing our country's children--and adults--has been a
    priority for me throughout my tenure in Congress. I was particularly
    pleased that the Economic Recovery Act contained an additional $300
    million over the next 2 years for immunizations for the uninsured and
    underinsured. But, once that funding runs out, the baseline funding
    that the President proposed would likely fall back to $500 million. As
    you may know, I have been joined by 17 of my colleagues in supporting
    more than $800 million in baseline funding to immunize this population.
    Have you given any thought to how you will fill the financial void
    after next year should funding fall back to $500 million?
        Answer. Historically, vaccines are one of the most successful and
    cost effective public health tools for preventing serious disease and
    death. The Center for Disease Control and Prevention's (CDC)
    immunization investments save lives and dollars by providing
    individuals and communities with a strong level of protection from
    vaccine-preventable diseases. The Recovery Act 317 section funding
    provided a historic opportunity to leverage section 317 immunization
    investments by augmenting existing public health capacity and federally
    purchased vaccines.
        In accordance with the Recovery Act, CDC is investing these funds
    in one-time efforts that will have the most health impact. The Recovery
    Act funding CDC received is being used to make vaccines available to
    more children, adolescents, and adults; help health departments learn
    how to improve their access to insurance reimbursement; increase
    awareness and provider education about immunization; and strengthen the
    evidence base for immunization policies and programs. These investments
    will have long-term benefits beyond the life of the funding by
    increasing the number of people vaccinated, providing immunization
    tools and resources for parents and healthcare providers, and assessing
    the impact of recently recommended vaccines to inform national vaccine
    policy.
                             pandemic preparedness
        Question. According to testimony before this panel on April 30, I
    understand that States have purchased only 23 million of the 31 million
    courses of antiviral treatments called for under the National Strategy
    on Pandemic Influenza. Rhode Island is only equipped with 10.5 percent
    of its allocation. Given the potentially urgent need for these
    medications, how does the Department of Health and Human Services plan
    to address the shortfall in State stockpiling efforts and prevent
    illness?
        Answer. Currently, State stockpiles have 24.5 million treatment
    courses. The Department is considering extending the Federal subsidy
    program for State antiviral stockpiling beyond the current end date of
    September 1, 2009, to allow States the ability to purchase up to an
    additional 4 million treatment courses during the fall and upcoming flu
    season necessitated by the current swine flu pandemic. States have
    already received 11 million treatment courses collectively from the
    Federal influenza antiviral drug stockpile in early May 2009 as a
    response measure for the H1N1 virus outbreaks in the United States
    These treatment courses pushed out to States from the Federal stockpile
    have now been added to each respective State stockpile total. For
    example, to use the case of Rhode Island, the Federal push of 25
    percent of their pro rata Federal allotment now added to their State
    stockpile (representing about 40,000 treatment courses) brings the new
    total to about 52,000 treatment courses. Therefore, Rhode Island is now
    equipped with about 46 percent of its State stockpile program pro rata
    allocation. Furthermore, the 11 million treatment courses in total
    pushed out from the Federal stockpile will also be replenished in full
    and that process is now underway. In addition, the Federal stockpile,
    which will be replenished to the initial 44 million treatment course
    level, will again be available in full for distribution to States
    should the need arise.
                              healthcare workforce
        Question. The Senate and the House are poised to have a meaningful
    debate on healthcare reform. With reform, we must also ensure that
    there is a workforce to adequately address the expected increase in
    patients. I am aware that the Economic Recovery Act contained an
    additional $200 million for title VII health professions programs.
    However, I am concerned that even with this increase, the funding level
    in the budget would not adequately address workforce shortages for
    years to come--especially in light of reform. In light of this, nearly
    half of my colleagues in the Senate have joined me in supporting $330
    million for title VII health professions programs. How did the
    administration account for the potential effects of healthcare reform
    in budgeting for an adequate primary care workforce?
        Answer. We are aware that with the expansion of coverage comes the
    need to provide primary care and other health services, particularly in
    areas that are currently underserved. Investments through the Recovery
    Act will assist in expanding and improving the efficiency of our
    provider workforce. We look forward to working with Congress to address
    the workforce needs that will arise from comprehensive health reform
                          conquer childhood cancer act
        Question. Last year, Congress passed and President Bush signed the
    Caroline Pryce Walker Childhood Cancer Act. Among other provisions,
    this law requires CDC to collect information on the causes, treatments,
    and effects of childhood cancer within weeks of learning of this
    information in a comprehensive childhood cancer registry.
    Individualized and aggregate data would dramatically enhance research
    initiatives and open the door for new, successful treatment options for
    patients. The CDC Cancer Registry line has been flat funded for years.
    Given the administration's effort to spur health innovation and
    research, how will you capitalize on these tangential, but important,
    research, and treatment tools?
        Answer. CDC collects and maintains individual level data on the
    diagnosis and treatment of childhood cancer cases in 45 States and the
    District of Columbia. The National Cancer Institute (NCI) collects
    similar data in the remaining 5 States and these data are combined to
    describe the incidence of cancer in the United States. Each year data
    are collected on approximately 12,000 to 13,000 cancer cases among
    children younger than 20 years of age. Data are collected on
    demographics, place of residence, type of cancer and stage at
    diagnosis, as well as first course of treatment. To fully understand
    the requirements for and feasibility of conducting national rapid case
    ascertainment for childhood cancers, CDC will host a meeting in the
    fall of 2009 which will include experts in childhood cancer research
    and cancer surveillance as well as critical partners such as the NCI
    and the American Cancer Society. One of the goals of this meeting will
    be to lay out all possible approaches that could be taken to address
    the data needs for childhood cancer research. In addition, optimal
    designs of a rapid-case ascertainment system will be described and
    explored for future planning.
        CDC supports and encourages research utilizing cancer registry
    data. For example, CDC provides data annually to the Central Brain
    Tumor Registry of the United States which conducts research and
    provides detailed data on benign and malignant brain tumors among
    children. In addition, CDC utilizes cancer registry data to report
    incidence and geographic variation of childhood cancer. CDC encourages
    and provides leadership in the use of State and national data for
    research into treatment and survival among children diagnosed with
    cancer and will establish collaborative relationships with the
    pediatric cancer community that are needed to promote this research.
    Working with State central cancer registries, CDC promotes the use of
    registry data for research purposes within the States and the District
    of Columbia. CDC is active in developing electronic reporting systems
    for cancer surveillance data which holds great promise in improving the
    timeliness of data.
                                     ______

                  Questions Submitted by Senator Thad Cochran
        Question. In your May 6 testimony on Health Reform in the 21st
    Century before the House Committee on Ways and Means, you noted the
    need for investments in prevention and wellness. In allocating those
    investments, will you devote any additional resources to the prevention
    of osteoporosis, a disease that 10 million Americans have and 34
    million are at risk for, and that costs our healthcare system an
    estimated $19 billion per year?
        Answer. The Recovery Act included $1 billion for prevention and
    wellness programs including $650 million for a prevention and wellness
    initiative. Details regarding this initiative will be announced this
    summer. Our health reform efforts will build on this initial investment
    in health reform by supporting proposals that improve access to
    appropriate clinical prevention services such as osteoporosis screening
    in postmenopausal women and community-based prevention interventions
    that target the main causes of chronic disease.
        Question. In addition to a renewed focus on prevention, many of the
    health reform proposals under consideration include programs for
    chronic disease management. Given that 10 million Americans have
    osteoporosis and another 2 million Americans suffer from other rare
    diseases of the bone like Paget's disease of the bone and osteogenesis
    imperfecta, will you include these bone diseases as part of such
    disease management programs?
        Answer. Yes. Osteoporosis is a classic example of a disease
    susceptible to chronic disease management. Models of chronic disease
    management apply to any disease that requires ongoing medical
    management and monitoring and will not be applied on a restrictive
    basis only to named diseases. This is why we feel it is important to
    avoid listing specific diseases for coverage--it implies that anything
    not listed is excluded. We take an entirely inclusive approach. The
    goal is to improve people's health.
                                     ______

                   Questions Submitted by Senator Judd Gregg
                          refugee resettlement program
        Question. As you know, the main objective of the refugee
    resettlement program is to assist refugees so they become self-
    sufficient in the shortest period of time. Unfortunately, the economic
    crisis has made it more difficult for refugees to achieve this goal,
    making programs that provide employment services all the more critical,
    especially the Voluntary Agency Matching Grant program, which enables
    refugees and other eligible persons to become self-sufficient within 4
    to 6 months from the date of arrival in the United States without
    resorting to Federal and State welfare programs. Leveraging public
    funds with private donations at a 2:1 ratio, the program currently
    serves approximately 27,000 individuals and is arguably the most
    successful job placement program for refugees with 80 percent of fiscal
    year 2008 participants achieving self-sufficiency. Given the overall
    objective of the refugee resettlement program, do you believe enough
    resources are being allocated to the Voluntary Agency Matching Grant
    program to maximize utility?
        Answer. The current economic conditions have made it more difficult
    for refugees to gain employment quickly, even for those in the Matching
    Grant program, which historically has been the most successful method
    for placing refugees into employment quickly. As a result, refugees and
    other eligible populations are accessing cash and medical assistance
    for longer periods of time, often for the full 8 months for which they
    are currently eligible. The number of refugees also is on the rise,
    and, for the first time since 2001, the number of arrivals appears to
    be approaching the refugee ceiling set by the State Department. Office
    of Refugee Resettlement will closely monitor arrivals and benefit
    access, and provide updated cost estimates to Congress as necessary,
    including resources provided to the Matching Grant program.
        Question. Recently, the administration requested additional funds
    to support efforts to combat H1N1 influenza, including the authority to
    use Project BioShield Special Reserve Funds (SRF) to fund the
    development and/or procurement of an H1N1 influenza vaccine. As you
    know, Congress created the Project Bioshield SRF to procure medical
    countermeasures against chemical, biological, radiological, and nuclear
    (CBRN) threats and appropriated $5.6 billion to remain available until
    2013. A transfer of funds from the Project Bioshield SRF could have a
    devastating impact on efforts to develop countermeasures for CBRN
    threats and call into question the Government's commitment to procure
    such products, which could force companies to scale back, or abandon,
    efforts to produce biosecurity products. Recognizing the importance of
    pandemic influenza preparedness, how does the Department intend to
    balance these two critical priorities in the near-term? What do you
    believe is the appropriate funding level for the SRF to adequately
    support near-term CBRN acquisitions and provide confidence to the
    biodefense industry?
        Answer. The Biomedical Advanced Research and Development Authority
    (BARDA) within the Department of Health and Human Services (HHS) Office
    of the Assistant Secretary for Preparedness and Response develops and
    procures medical countermeasures for CBRN threats, pandemic influenza,
    and emerging infectious diseases. BARDA programs are funded through the
    SRF (CBRN countermeasure procurement), pandemic influenza funding
    (including for advanced development and procurement), and annual
    appropriations for advanced research and development (CBRN
    countermeasures). HHS' intent is to continue to utilize the SRF and
    annual advanced development appropriations for their intended uses
    (i.e., the procurement and development of CBRN countermeasures,
    respectively).
        Project BioShield was funded through the Department of Homeland
    Security (DHS) Appropriations Act of 2004 (Public Law 108-90) which
    established the SRF by advance-appropriating $5.6 billion for the
    procurement of countermeasures against CBRN agents from fiscal year
    2004 to fiscal year 2013. The act allows the HHS Secretary, with
    concurrence from the DHS Secretary and approval from the Director of
    OMB, to develop and procure products that are within 8 years of FDA
    approval. DHS has issued Material Threat Determinations and Population
    Threat Assessments for 13 CBRN agents, upon which the BARDA
    Implementation Plan is based. To date BARDA has obligated $2 billion of
    the Special Reserve Fund on 5 CBRN programs that have delivered anthrax
    vaccines and therapeutics, botulinum antitoxins, and radiological drugs
    to the Strategic National Stockpile. In fiscal year 2009, Congress
    transferred $412 million from the SRF to support CBRN advanced
    development and pandemic influenza. The fiscal year 2010 President's
    budget proposes transferring $305 million from the SRF for CBRN
    Advanced Development. The long-term success of Project BioShield is
    directly tied to the success of the Advanced Development program. Over
    the next 4 years, BARDA will obligate the remaining $2.9 billion in the
    SRF by expanding its portfolio of late-stage products in anthrax
    vaccines, smallpox antivirals, chemical agent antidotes, and other
    radiological drugs in order to develop next-generation products.
                                     ______

               Question Submitted by Senator Kay Bailey Hutchison
                            medical countermeasures
        Question. In addition to the recently circulating H1N1 and H5N1
    influenza strains, there is a host of emerging infectious diseases and
    biothreat agents for which we need to develop medical countermeasures
    in order to protect the health of the American people. In light of the
    broad range of possible biothreats, as well as the long lag time and
    high costs associated with developing drugs, how does HHS plan to
    transition R&D into these lifesaving countermeasures in quantities
    large enough to cover our population? And how does HHS plan to
    disseminate them rapidly enough to be able to make a difference in the
    event of an outbreak or attack?
        Answer. HHS has implemented the Public Health Emergency Medical
    Countermeasures Enterprise (PHEMCE) to manage the development and
    deployment of CBRN countermeasures, from the basic research phase at
    NIH to procurement through Project BioShield. The PHEMCE is a
    coordinated, inter-agency effort led by the HHS Assistant Secretary for
    Preparedness and Response and includes the Centers for Disease Control
    and Prevention, Food and Drug Administration, and the National
    Institutes of Health (NIH). Ex officio members include the Department
    of Homeland Security, Department of Veterans Affairs, and the
    Department of Defense. The PHEMCE defines and prioritizes CBRN medical
    countermeasure (MCM) requirements, integrates and coordinates research,
    development, procurement, and deployment and use strategies for MCMs.
    The investment in biodefense research and development has led to
    fundamental discoveries and has laid the foundation for promising drugs
    and vaccines for biodefense purposes. To date, two programs started at
    NIH have reached the level of maturity required for consideration into
    a late-stage development program funded under Project BioShield (i.e.,
    product is within 8 years of FDA approval). Once products are procured
    through Project BioShield, they are placed in the Strategic National
    Stockpile (SNS). The SNS works with State and local partners to ensure
    that medical countermeasures can be distributed as quickly as possible
    during a public health emergency.

                             CONCLUSION OF HEARINGS

        Senator Harkin. The subcommittee will stand recessed.
        [Whereupon, at 3:32 p.m., Tuesday, June 9, the the hearings
    were concluded, and the subcommittee was recessed, to reconvene
    subject to the call of the Chair.]

      DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES, AND EDUCATION, AND
              RELATED AGENCIES APPROPRIATIONS FOR FISCAL YEAR 2010

                                  ----------

                                           U.S. Senate,
               Subcommittee of the Committee on Appropriations,
                                                        Washington, DC.

                           NONDEPARTMENTAL WITNESSES

        [Clerk's note.--The subcommittee was unable to hold
    hearings on nondepartmental witnesses. The statements and
    letters of those submitting written testimony are as follows:]
                       Prepared Statement of AIDS Action
        I am pleased to submit this testimony to the members of this
    subcommittee on the importance of increased funding for the fiscal year
    2010 HIV/AIDS portfolio. Since 1984, AIDS Action Council, through its
    member organizations and the greater HIV/AIDS and public health
    communities, has worked to enhance HIV prevention programs, research
    protocols, and care and treatment services at the community, State and
    Federal level. AIDS Action represents many AIDS service organizations
    located in the Nation's HIV epicenters, local health departments,
    smaller service providers, faith-based organizations, substance abuse
    treatment centers, and education and advocacy organizations from all
    over the country. AIDS Action's goals are to ensure effective,
    evidence-based HIV care, treatment, and prevention services; to
    encourage the continuing pursuit of a cure and a vaccine for HIV
    infection; and to support the development of a public health system
    which ensures that its services are available to all those in need. On
    behalf of AIDS Action Council's diverse membership I bring your
    attention to issues impacting funding for fiscal year 2010.
        Nearly 30 years since it was first identified, the HIV/AIDS
    epidemic in the United States is characterized by needless mortality,
    inadequate access to care, persistent levels of new infection, and
    stark racial inequalities. Despite the good news of improved
    treatments, which have made it possible for people with HIV disease to
    lead longer and healthier lives, stark realities remain. Consider that
    in the United States:
      --Every year, 56,300 people are newly infected with HIV--one new
            infection every 9\1/2\ minutes. According to the Centers for
            Disease Control and Prevention (CDC) the HIV infection rate has
            not fallen in 15 years and the new incidence figure represent a
            40 percent increase from previous estimates
      --CDC stated that the HIV incidence rate increased by 15 percent from
            2006 to 2007.
      --More than 1 million people are living with HIV or AIDS; an
            estimated half of people living with HIV/AIDS are not in care.
      --Of those people living with HIV/AIDS 21 percent are unaware of
            their HIV status.
      --CDC estimates in 2007, 14,561 people died from AIDS-related causes.
      --African Americans represent 13 percent of the population but nearly
            half of all newly reported HIV infections.
      --Hispanics/Latinos represent 13 percent of the population, but
            account for 18 percent of newly reported cases of HIV.
      --The percentage of newly reported HIV/AIDS cases in the United
            States. among women tripled from 8 percent to 27 percent
            between 1985 and 2007.
      --AIDS is the leading cause of death among Black women aged 25-34
      --HIV is the No. 1 healthcare risk for gay men and men who have sex
            with men, especially in communities of color.
      --More than half of all newly diagnosed individuals are identified
            with full-blown AIDS in less than 12 months of their initial
            diagnosis.
      --There is neither a cure nor a vaccine for HIV and current
            treatments do not work for everyone.
        The Federal Government's commitment to funding prevention,
    research, and care and treatment for those living with HIV is critical.
    We would be unable to respond to this epidemic without the Federal
    Government's increased commitment to funding HIV programs at home.
    However, we are not doing enough. The unsatisfactory outcomes from our
    country's response to AIDS have serious human and economic costs. A
    study published in 2003 found that failure to meet the Government's
    then goal of reducing HIV infections by half would lead to $18 billion
    in excess expenses through 2010. We need more prevention, more
    treatment and care and more research if we are ever to slow and
    eventually reverse the HIV epidemic.
        It is AIDS Action's expectation that the Congress, through the good
    work of this subcommittee, will recognize and address the true funding
    needs of the programs in the HIV/AIDS portfolio. HIV is a 100 percent
    preventable disease that can be lessened with a focused, concentrated
    effort and increased funding. The community has come together under the
    umbrella of the AIDS Budget and Appropriations Coalition with the
    community funding request for the HIV/AIDS domestic portfolio for
    fiscal year 2010. The numbers requested represent that community work.
    These requests have been submitted to the subcommittee.
        CDC estimate that approximately 13 percent of all HIV cases and
    approximately 60 percent of all hepatitis C cases in the United States
    are directly or indirectly related to intravenous drug use. One of the
    most important ways to reduce these epidemics is through the use of
    syringe exchange. More than eight Federal studies along with numerous
    scientific peer-reviewed papers published more than 15 years have
    conclusively established that syringe exchange programs reduce the
    incidence of HIV among people who inject drugs and their sexual
    partners. Such studies have all concluded that syringe exchange does
    not increase drug abuse. Instead, syringe exchange programs connect
    people who use drugs to healthcare services including addiction
    treatment, HIV and viral hepatitis prevention services and testing,
    counseling, education, and support.
        The ban on Federal funding for syringe exchange is
    counterproductive and limits the ability of local and State
    jurisdictions to respond effectively to the twin HIV and hepatitis
    epidemics. AIDS Action and the HIV community recommends that the
    subcommittee remove any language prohibiting the use of Federal funds
    to establish or carry out a program of distributing sterile syringes to
    reduce the transmission of blood borne pathogens, including the human
    immunodeficiency virus (HIV) and viral hepatitis.
        According to CDC estimates contained in the agency's March 2006
    HIV/AIDS Surveillance Report, 1,014,797 cumulative cases of AIDS have
    been diagnosed in the United States, with a total of 565,927 deaths
    since the beginning of the epidemic. As noted above, the CDC estimates
    that between 1.1 and 1.2 million people are living with HIV/AIDS and
    that 250,000-350,000 people are unaware of their status and could
    unknowingly transmit the virus to another person. As funding has
    remained essentially flat for more than 8 years, money has shifted to
    new and needed HIV testing efforts and initiatives. As a result, grants
    to States and local communities have significantly decreased and new
    infections have increased to an estimated 56,300 per year, according to
    a CDC report released in August 2008. Therefore, AIDS Action Council,
    the HIV community, and the CDC in their budget justification before
    Congress September 2008, estimates that the CDC HIV Prevention and
    Surveillance programs will need $1.5 billion, an increase of $878
    million, in fiscal year 2010 to address the true unmet needs of
    preventing HIV in the United States. In the United States, HIV is
    transmitted primarily through sex. In order to combat the rising rates
    of transmission, we must ensure that sexuality education programs are
    medically sound and effective in fostering healthy behavior over the
    long-term. Abstinence is an important component of comprehensive
    sexuality education and HIV prevention programs; however, when it is
    advocated as the only option for young people, research has shown that
    it is ineffective, unrealistic, and potentially harmful. We believe the
    Federal Government should only support those sexuality education and
    HIV-prevention programs that are evidence-based. For that reason we
    support the elimination of all funding for the Community-Based
    Abstinence Education (CBAE) programs. All such funds should be re-
    directed to evidence-based prevention and educational programs. This
    past World AIDS Day, President Obama affirmed that, ``My administration
    will .work with Congress to enact an extensive program of prevention,
    including access to comprehensive age-appropriate sex education for all
    school age children.'' We request that at least $50 million be
    allocated to promote comprehensive sex education in our schools and
    communities nationwide.
        Now in its 19th year, The Ryan White Comprehensive AIDS Resources
    Emergency (CARE) Act, administered by the Health Resources and Services
    Administration (HRSA) and funded by this subcommittee, provides
    services to more than 533,000 people living with and affected by HIV
    throughout the United States and its territories. It is the single
    largest source of Federal funding solely focused on the delivery of HIV
    services; it provides the framework for our national response to the
    HIV epidemic. CARE Act programs have been critical to reducing the
    impact of the domestic HIV epidemic. Yet in recent years, CARE Act
    funding has not kept pace with the epidemic and has decreased through
    across-the-board rescissions. It is important to remember that CARE Act
    programs are designed to compliment each other. It is necessary that
    all parts of the CARE Act receive substantial increased funding to
    ensure the success of the total program. AIDS Action and the HIV/AIDS
    community estimate that the entire Ryan White CARE Act portfolio needs
    $2.816 million in fiscal year 2010, an increase of $577.8 million to
    address the true needs of the hundreds of thousands of people living
    with HIV who are uninsured, underinsured, or who lack financial
    resource for healthcare.
        Part A of The Ryan White CARE Act now includes five additional
    Transitional Grant Areas (TGAs). Some of the services provided under
    part A include physician visits, laboratory services, case management,
    home-based and hospice care, and substance abuse and mental health
    services. Under the most recent reauthorization these services are even
    more dedicated towards funding core medical services and to ensuring
    the ability of patients to adhere to treatment. These services are
    critical to ensuring patients have access to, and can effectively
    utilize, life-saving therapies. AIDS Action along with the HIV/AIDS
    community recommends funding part A at $766.1 million, an increase of
    $103 million.
        Part B of the CARE Act ensures a foundation for HIV related
    healthcare services in each State and territory, including the
    critically important AIDS Drug Assistance Program (ADAP). Part B base
    grants (excluding ADAP) received a decrease of $28.5 million in fiscal
    year 2009. AIDS Action along with the HIV/AIDS community recommends
    funding for part B base grants at $514.2 million, an increase of $105.4
    million.
        The AIDS Drug Assistance Program (ADAP) provides medications for
    the treatment of individuals with HIV who do not have access to
    Medicaid or other health insurance. According to the 2009 National ADAP
    Monitoring Project, ADAP provided medications to approximately 183,299
    clients in fiscal year 2007, including 36,354 new clients. AIDS Action
    along with the HIV/AIDS community recommends $1,083 million, an
    increase of $268.6 million, for ADAP for fiscal year 2010. This
    ``community need'' number is derived from a pharmacoeconomic model to
    estimate the amount of funding needed to treat ADAP eligible
    individuals in upcoming Federal and State fiscal years. The need number
    represents the amount of new funding required to allow State ADAPs to
    provide a minimum clinical standard formulary of HIV/AIDS medications
    to ADAP clients under the current eligibility rules for each State.
        Part C of the Ryan White CARE Act awards grants to community-based
    clinics and medical centers, hospitals, public health departments, and
    universities in 22 States and the District of Columbia under the Early
    Intervention Services program. These grants are targeted toward new and
    emerging sub-populations impacted by the HIV epidemic. Part C funds are
    particularly needed in rural areas where the availability of HIV care
    and treatment is still relatively new. Urban areas continue to require
    part C funds as emerging populations as grantees struggle to meet the
    needs of previously identified HIV positive populations. AIDS Action,
    along with the HIV/AIDS community, requests $268.3 million, an increase
    of $66.4 million, for part C.
        Part D of the Ryan White CARE Act awards grants under the
    Comprehensive Family Services Program to provide comprehensive care for
    HIV positive women, infants, children, and youth, as well as their
    affected families. These grants fund the planning of services that
    provide comprehensive HIV care and treatment and the strengthening of
    the safety net for HIV positive individuals and their families. AIDS
    Action and the HIV/AIDS community request $134.6 million, an increase
    of $57.7 million, for Part D.
        Under Part F, the AIDS Education and Training Centers (AETCs) is
    the training arm of the Ryan White CARE Act; they train the healthcare
    providers, including the doctors, advanced practice nurses, physicians'
    assistants, nurses, oral health professionals, and pharmacists. The
    role of the AETCs is invaluable in ensuring that such education is
    available to healthcare providers who are being asked to treat the
    increasing numbers of HIV positive patients who depend on them for
    care. Additionally, the AETCs have been tasked with providing training
    on Hepatitis B and C to CARE Act grantees and to ensure inclusion of
    culturally competent programs for and about HIV and Native Americans
    and Alaska natives. However no funding has been added for additional
    materials, training of staff, or programs. The AETCs received a modest
    increase of $0.3 million in fiscal year 2009. AIDS Action and the HIV/
    AIDS community request $50 million, a $15.6 million increase, for this
    program. Also under part F, Dental care is another crucial part of the
    spectrum of services needed by people living with HIV disease. Oral
    health problems are often one of the first manifestations of HIV
    disease. Unfortunately oral health is one of the first aspects of
    healthcare to be neglected by those who cannot afford, or do not have
    access to, proper medical care removing an opportunity to catch early
    infections of HIV. AIDS Action and the HIV/AIDS community request $19
    million, a $5.6 million increase, for this program. Finally under part
    F, rising infections and strapped care systems necessitate the research
    and development of innovative models of care. The SPNS program is
    designed for this purpose and must continue to receive sufficient
    funding.
        The Minority AIDS Initiative directly benefits racial and ethnic
    minority communities with grants to provide technical assistance and
    infrastructure support and strengthen the capacity of minority
    community based organizations to deliver high-quality HIV healthcare
    and supportive services to historically underserved groups. HIV/AIDS in
    the United States continues to disproportionately affect communities of
    color. According to the CDC in 2006, the overall rate of HIV diagnosis
    (the number of diagnoses per 100,000 population) in the 33 States (that
    currently report HIV data) was 18.5 per 100,000. The rate for blacks
    was roughly 8 times the rate for whites (67.7 per 100,000 vs 8.2 per
    100,000). The Minority AIDS Initiative provides services across every
    service category in the CARE Act and was authorized for inclusion
    within the CARE Act for the first time in the 2006 CARE Act
    reauthorization. It additionally funds other programs throughout HHS
    agencies. AIDS Action and the HIV/AIDS community request a total of
    $610 million for the Minority AIDS Initiative.
        Research on preventing, treating, and ultimately curing HIV is
    vital to the domestic and global control of the disease. It is
    essential that Office of AIDS Research continue its groundbreaking
    research in both basic and clinical science to develop a preventative
    vaccine, microbicides, and other scientific, behavioral, and structural
    HIV prevention interventions. The United States must continue to take
    the lead in the research and development of new medicines to treat
    current and future strains of HIV. NIH's Office of AIDS Research is
    critical in supporting all of these research arenas. Commitment in
    research will ultimately decrease the care and treatment dollars needed
    if HIV continues to spread at the current rate. AIDS Action requests
    that the NIH be funded at $34 billion in fiscal year 2010 and that the
    AIDS portfolio must be funded at $3.4 billion a $500 million increase.
        HIV is a continuing health crisis in the United States. We must
    continue to work to fully fund our domestic prevention, treatment and
    care, and research efforts. On behalf of all HIV positive Americans,
    and those affected by the disease, AIDS Action Council urges you to
    increase funding in each of these areas of the domestic HIV/AIDS
    portfolio. Help us save lives by allocating increased funds to address
    the HIV epidemic in the United States.
                                     ______

               Prepared Statement of the Alzheimer's Association
        Mr. Chairman and members of the subcommittee: As President and CEO
    of the Alzheimer's Association, I want to take this opportunity to
    thank you for the leadership role this subcommittee has played over the
    years in the fight to conquer Alzheimer's disease.
        Indeed, it was this subcommittee that first drew attention to
    Alzheimer's disease in its fiscal year 1982 appropriations report. At
    the time, an estimated 2.5 million people were thought to be suffering
    with Alzheimer's disease, their families quietly bearing most of the
    financial, physical, and emotional burden of care giving. Even if they
    were personally affected, relatively few Americans had even heard of
    Alzheimer's disease because so many went undiagnosed or were
    inaccurately diagnosed; far fewer were aware of the crisis just
    beginning to unfold. All this is still too true today.
        Alzheimer's disease now is now estimated to afflict more than 5
    million Americans. It is in a virtual tie as the Nation's sixth leading
    cause of death, while significantly underreported and growing. It is
    already the third most expensive disease, draining billions of dollars
    from our economy every year. But the story does not end with those grim
    statistics because this problem is not going to age itself away. On the
    contrary, as Baby Boomers shoulder their way into the age of highest
    risk, we will see 10 million members of this generation fall victim to
    Alzheimer's disease.
        At times called the quiet epidemic, the great unlearning or the
    long dying, year by year Alzheimer's disease strips away memory,
    personality and independence, leaving its victims unable to handle the
    most basic functions of daily living. For those who do not succumb to
    pneumonia or other complications of Alzheimer's, there is the final act
    of forgetting--when the brain forgets to breathe.
        But make no mistake the effects of Alzheimer's extend well beyond
    the human suffering and the physical and emotional strain it puts on
    families. Indeed, despite all that is challenging America today,
    Alzheimer's disease represents a grave threat to our Nation's social
    and economic well-being.
        This year, Medicare and Medicaid will spend more than $100 billion
    to finance care for those struggling with Alzheimer's disease. Over the
    next 40 years, those two programs alone will spend almost $20 trillion
    on the care of Alzheimer patients.
        Unless we find a way to prevent or slow its progression, by the
    year 2050 the annual cost of this disease to Medicare and Medicaid
    programs alone will be equal to one-tenth of our entire current
    domestic economy.
        Alzheimer's disease is so expensive because, in addition to its
    direct costs, it greatly increases the use and costs of Medicare to
    treat other serious medical conditions. Ninety-five percent of Medicare
    beneficiaries with Alzheimer's disease have at least one co-morbid
    condition. Tasks such as medication management become extremely
    difficult and time-consuming. As a result, the health and long-term
    care costs of treating these individuals is more than three times that
    of a Medicare beneficiary without Alzheimer's disease.
                           bold action is needed now
        Over the years this body has exercised its prerogative to channel
    funds to the Nation's most pressing public health problems. Added funds
    provided by this subcommittee led to cancer patients living longer,
    with many beating the disease. Thanks to those investments, survival
    rates have steadily improved for breast, prostate, colorectal and some
    other types of cancer, so that today, the 5-year relative survival rate
    is 66 percent across all cancers. According to the most recent
    estimates, 10.8 million Americans with a history of cancer are alive
    today. As a result of this subcommittee's strong and sustained
    investment in cardiovascular disease research, death rates from heart
    disease and stroke fell by 40 percent and 51 percent, respectively,
    since 1975. And when challenged by the HIV/AIDS epidemic, this
    subcommittee responded quickly and decisively--providing a research
    investment that yielded vastly improved treatments and prevention
    strategies and a two-thirds reduction in annual deaths.
        Mr. Chairman, unlike cancer, cardiovascular disease and so many
    other chronic conditions that have dramatically improved with
    significant investments in research, there are no Alzheimer's disease
    survivors. None. We cannot prevent, halt or reverse it. Every day some
    of the 5 million who have it die of this fatal disease, only to be
    replaced by even more who will progressively decline and die, as more
    replace them. Indeed, the only way to avert this rapidly developing
    social and economic catastrophe is if this subcommittee, once again,
    leads the way.
        Past investments in Alzheimer's research have helped bring us to a
    point no one would have dreamed possible when this subcommittee first
    called attention to this disease. Scientists now have a much clearer,
    but still incomplete picture of the basic mechanisms of Alzheimer's;
    epidemiological research is shedding light on new targets for
    intervention that now must be tested in large-scale clinical trials.
    And work is underway to help identify potential uses of imaging and
    other surrogate markers to follow the progression of cognitive decline,
    and to assess the effectiveness of drug interventions. But we still
    have so much to accomplish.
        Much of what we have learned came about because Congress invested
    in Alzheimer research throughout the 1980s and 1990s. But even those
    investments were not commensurate with the impact of the disease. The
    evidence from cancer and cardiovascular disease illustrates the returns
    that can be derived from additional investments in Alzheimer's research
    now. As the mortality rates for cancer and heart disease decline,
    Alzheimer's is still rising at a steady and rapid pace.
        In fact, during the past 6 years we have seen a dramatic slowdown
    in overall research investments, signaling a slowdown in advances to
    come, but the effects on Alzheimer research are potentially greater as
    the funding stalled at such a comparatively low level. Today, the
    National Institutes of Health (NIH) devotes only $412 million a year
    for research on Alzheimer's disease--far short of the $1 billion that
    leading scientific minds estimate as the minimum required investment to
    uncover ways to prevent, slow and more effectively treat this disease.
    That $412 million is also considerably less than what is spent for
    research on other major threats to society, such as cancer,
    cardiovascular disease, and AIDS. All of these problems merit
    significant investments, but Alzheimer's research is underfunded when
    measured against the suffering inflicted by the disease or by the
    potential cost savings in care that could be gained by investing in
    research today--before it's too late.
        What can the subcommittee do to help stop this serious threat to
    America's future?
        First and foremost, the Alzheimer's Association recommends that you
    appropriate an additional $250 million this year and next to raise the
    total NIH investment in Alzheimer's research up to $1 billion. These
    added funds will be put to use in three crucial areas:
      --Clinical Trials.--The funding of clinical trials and
            epidemiological studies, particularly through the Alzheimer's
            Disease Cooperative Study (ADCS) national research consortium
            funded by the NIH, are identifying new targets for
            interventions, including compounds that are already widely
            available such as over-the-counter medications. Time is not on
            our side. If we hope to forestall this looming crisis, large-
            scale clinical trials must be undertaken soon and must be
            launched simultaneously, not sequentially.
      --Early Markers of Disease.--Earlier diagnosis is critical if we hope
            to stop the disease before it ravages brain cells beyond
            repair. Additional resources are sorely needed to fully fund
            the next phase of a neuro-imaging initiative currently being
            supported at the National Institute on Aging.
      --Basic Science Research.--Science must find new answers and ask
            better questions. While significant progress has been made,
            scientists are still searching for definitive answers to
            questions about the basic mechanisms of Alzheimer's disease.
            Congress must maintain the pipeline of basic scientific
            discovery to develop additional targets for treatment. At
            current funding levels, work on promising avenues of research
            is either delayed or never started. Young investigators--and
            their fresh new ideas--are discouraged from entering this field
            of study.
        While research holds the answers, there are other steps we
    recommend you take to help forestall or lessen the impact of
    Alzheimer's.
               expand the healthy brain initiative to $5 million
        Four years ago, this subcommittee launched the first single-focused
    effort on brain health promotion at the Centers for Disease Control and
    Prevention (CDC). As a result of the investment that has been made in
    the Healthy Brain Initiative, the CDC, in partnership with the
    Alzheimer's Association, has developed a public health roadmap for
    maintaining cognitive health, implemented community education programs
    targeting African-American baby boomers, and developed modules for
    enhancing the surveillance system for cognitive decline.
        The impetus for this program was the mounting scientific evidence
    suggesting that brain health may be maintained by preventing or
    controlling cardiovascular risk factors, such as high blood pressure,
    high cholesterol and diabetes, and by engaging in regular physical
    activity. In light of the dramatic aging of the population, scientific
    advancements in risk behaviors, and the growing awareness of the
    significant health, social and economic burdens associated with
    cognitive decline, the Federal investment in a public health response
    must be expanded. We recommend that this program be increased to $5
    million to focus on the following activities:
      --Healthy Brain Engagement Initiative.--The promising approaches that
            have been identified through the community education programs
            need to be expanded to additional locations and new target
            audiences to impact attitudes and behaviors related to
            cognitive health. Particularly, we must focus on other high-
            risk and underserved populations, specifically the Hispanic/
            Latino population.
      --Tracking Cognitive Impairment as America Ages.--In order to
            accelerate the availability of data to clarify the burden of
            Alzheimer's, an enhanced surveillance system for cognitive
            health is required. This can be achieved through implementation
            of appropriate Behavioral Risk Factor Surveillance System
            (BRFSS) modules in as many States as possible. The development
            and testing of BRFSS modules is currently underway and will be
            available for use in 2010.
      --Tools for Care Coordination in the Face of Cognitive Impairment.--
            Cognitive health challenges--from mild cognitive decline to
            dementia--can have profound implications on an individual's
            ability to self-manage other coexisting conditions. In order to
            effectively address this challenge, interventions that target
            the coordination of care for those with cognitive impairment
            and coexisting chronic diseases will be adapted or developed.
      --Early Detection.--Early recognition of Alzheimer's, an accurate
            diagnosis, and early intervention, including medication, can
            significantly improve the quality of life and mental function
            of people with the disease. Communications strategies that
            provide information on the signs and symptoms of the disease
            and options for maintaining brain health will be developed and
            disseminated, targeting consumers and providers.
     continue alzheimer's disease demonstration grants and the alzheimer's
                                 contact center
        The Administration on Aging (AoA) operates two Alzheimer-related
    programs that warrant continuation. The first is a program of matching
    grants to States for the development of innovative, community-based
    services for Alzheimer patients and caregivers, especially hard-to-
    reach and underserved populations. For this program, we recommend an
    appropriation of $11.6 million.
        In 2003, this subcommittee launched the Alzheimer's Contact Center,
    a nationwide call-in program that provides families in crisis with
    around-the-clock support and assistance. Services include access to
    professional clinicians who provide decision-making support, crisis
    assistance and referrals. In 2008, the center fielded more than 106,000
    calls from families. The Alzheimer's Association recommends you
    appropriate $1 million to continue this valuable service.
        Each of the recommendations I have outlined fall within the purview
    of this subcommittee. But I would also like to call your attention to a
    report issued recently, called A National Alzheimer's Strategic Plan:
    The Report of the Alzheimer's Study Group.
        This landmark report was the culmination of nearly 2 years of work
    by an independent task force of prominent national leaders. It was co-
    chaired by former Speaker of the House Newt Gingrich and former U.S.
    Senator Bob Kerrey, and included other distinguished individuals such
    as former Supreme Court Justice Sandra Day O'Connor and Drs. Harold
    Varmus, David Satcher, and Mark McClellan. The Alzheimer's Study Group
    also drew on the knowledge and expertise of more than 100 experts in
    various facets of this disease.
        Mr. Chairman, in a word, the Alzheimer's Study Group concluded that
    to achieve a world without Alzheimer's disease we do not need to re-
    invent the wheel; but we have to make it work more efficiently.
        This report contains many important recommendations, including
    developing the capability to prevent Alzheimer's disease in 90 percent
    of individuals by 2020. But one that warrants special attention within
    the context of this subcommittee's deliberations is the creation of an
    outcomes-oriented, objective-driven Alzheimer's Solutions Project
    Office within the Federal Government. With support from the president
    and Congress, this effort would oversee a decade-long mission to
    undertake a coordinated and sustained attack on Alzheimer's disease.
        Mr. Chairman, thank you for your time and attention. Should you
    have any questions or require additional information, please feel free
    to call on me.
                                     ______

      Prepared Statement of the Association of American Cancer Institutes
        The Association of American Cancer Institutes (AACI), representing
    95 of the Nation's premier academic and free-standing cancer centers,
    appreciates the opportunity to submit this statement for consideration
    as the Labor, Health and Human Services, and Education, and Related
    Agencies subcommittee plans the fiscal year 2010 appropriations for the
    National Institutes of Health (NIH) and the National Cancer Institute
    (NCI).
        AACI applauds recent budgetary commitments--notably, increased
    funding for NIH and support from the Obama administration through the
    American Recovery and Reinvestment Act of 2009--that have created a
    more encouraging landscape for cancer research compared to the last 5
    years. While AACI understands and appreciates the budgetary constraints
    currently facing our Nation, we also believe that advances in cancer
    and biomedical research must remain a very high national priority.
    Therefore, we hope that high levels of support will continue in the
    years ahead, to ensure that this recognition of the importance of
    biomedical research is sustained.
        For fiscal year 2010, AACI joined its colleagues in the biomedical
    research community in supporting the request in the President's initial
    budget proposal for $6 billion in funding for cancer research in fiscal
    year 2010, and his commitment to double funding for cancer research
    over the next 5 years.
        AACI also requests that total funding to NIH be increased by 10
    percent, including a 20 percent increase for NCI and a 7 percent
    increase for the other Institutes and Centers within NIH. The Nation's
    investment in the NIH and NCI helps lead to scientific advances that
    can save lives and improve the health of Americans. Early funding
    increases helped speed the pace of cancer research, and this investment
    can be leveraged significantly with a renewed commitment to strong,
    sustained Federal funding of medical research and, in particular,
    cancer research. AACI will work to ensure that Congress approves the
    maximum possible appropriations for NIH and NCI.
                           the growing cancer burden
        In 2008, there were approximately 1.44 million new cases of cancer
    in the United States and approximately 565,650 deaths due to the
    disease.\1\ About 150,090 new cancer cases were expected to be
    diagnosed among African Americans in 2009, with about 63,360 expected
    to die from the disease. In men, the death rate for all cancers
    combined continued to be substantially higher among African Americans
    than whites during 1975-2005. Similar trends were seen among women,
    although the gap is much smaller.\2\
    ---------------------------------------------------------------------------
        \1\ Cancer Facts and Figures 2008. American Cancer Society; 2008.
    (The publication of Cancer Facts & Figures 2009 has been delayed due to
    the late release of the US final mortality data by the National Center
    for Health Statistics.)
        \2\ American Cancer Society. Cancer Facts & Figures for African
    Americans 2009-2010. Atlanta: American Cancer Society, 2009.
    ---------------------------------------------------------------------------
        Looking further into the future, the need for cancer care will
    expand dramatically. From 2010 to 2030, the total projected cancer
    incidence will increase by approximately 45 percent, from 1.6 million
    in 2010 to 2.3 million in 2030. This increase is driven by cancer
    diagnosed in older adults and minorities. A 67 percent increase in
    cancer incidence is anticipated for older adults, compared with an 11
    percent increase for younger adults. A 99 percent increase is
    anticipated for minorities, compared with a 31 percent increase for
    whites. From 2010 to 2030, the percentage of all cancers diagnosed in
    older adults will increase from 61 percent to 70 percent, and the
    percentage of all cancers diagnosed in minorities will increase from 21
    percent to 28 percent.\3\
    ---------------------------------------------------------------------------
        \3\ Smith et al., ``Future of Cancer Incidence in the United
    States: Burdens Upon an Aging, Changing Nation'', J Clin Oncol 2009; 27
    ---------------------------------------------------------------------------
        The human toll of cancer is staggering, as is its financial toll;
    the NCI reports that in 2006, $206.3 billion was spent on healthcare
    costs for cancer alone. Additionally, NCI acknowledges that the burdens
    of cancer--physical, emotional, and financial--are ``unfairly
    shouldered by the poor, the elderly, and minority populations.'' The
    number of cancer diagnoses will only continue to climb as our
    population ages, with an estimated 18.2 million cancer survivors (those
    undergoing treatment, as well as those who have completed treatment)
    alive in 2020.
                   cancer research: benefiting all americans
        Cancer research, conducted in academic laboratories across the
    country saves money by reducing healthcare costs associated with the
    disease, enhances the United States' global competitiveness, and has a
    positive economic impact on localities that house a major research
    center. While these aspects of cancer research are important, what
    cannot be overstated is the impact cancer research has had on
    individuals' lives--lives that have been lengthened and even saved by
    virtue of discoveries made in cancer research laboratories at cancer
    centers across the United States.
        Though more than a half-million Americans will die this year from
    the many diseases defined as cancer, progress is being made. Because of
    continued progress made by the Nation's researchers, cancer death rates
    have continued to decline; between 1991 and 2004, the death rates for
    cancer in men and women declined 18.4 percent and 10.5 percent,
    respectively.\4\ Similarly, death rates among African Americans for all
    cancers combined have been decreasing since 1991 after increasing from
    1975 to 1991. The decline was larger in men (2.5 percent per year since
    1995) than in women (1.3 percent per year since 1997). Similar trends
    were observed among whites from 1991-2005, with a greater reduction in
    the rate among men than women.
    ---------------------------------------------------------------------------
        \4\ Cancer Statistics, 2008. CA: Cancer Journal for Clinicians
    2008; 58(2): 71-96.
    ---------------------------------------------------------------------------
        Biomedical research has provided Americans with better cancer
    treatments, as well as enhanced cancer screening and prevention
    efforts. Some of the most exciting breakthroughs in current cancer
    research are those in the field of personalized medicine. In
    personalized medicine for cancer, not only is the disease itself
    considered when determining treatments, but so is the individual's
    unique genetic code. This combination allows physicians to better
    identify those at risk for cancer, detect the disease, and treat the
    cancer in a targeted fashion that minimizes side effects and refines
    treatment in a way to provide the maximum benefit to the patient.
        In the laboratory setting, multi-disciplinary teams of scientists
    are working together to understand the significance of the human genome
    in cancer. For instance, the Cancer Genetic Markers of Susceptibility
    initiative is comparing the DNA of men and women with breast or
    prostate cancer with that of men and women without the diseases to
    better understand the diseases. The Cancer Genome Atlas is in
    development as a comprehensive catalog of genetic changes that occur in
    cancer. Another initiative, the Childhood Cancer Therapeutically
    Applicable Research to Generate Effective Treatments Initiative, is
    identifying targets that can lead to better treatments for young people
    with cancer.
        These projects--along with the work being performed by dedicated
    physicians and researchers at cancer centers across the United States
    every day--have the potential to radically change the way cancer, as a
    collection of diseases, affects the people who live with it every day.
    Every discovery contributes to a future without cancer as we know it
    today.
                          the nation's cancer centers
        The nexus of cancer research in the United States is the Nation's
    network of cancer centers that are represented by AACI. These cancer
    centers conduct the highest-quality cancer research anywhere in the
    world and provide exceptional patient care. The Nation's research
    institutions, which house AACI's member cancer centers, receive an
    estimated $3.17 billion \5\ from NCI to conduct cancer research; this
    represents 66 percent of NCI's total budget. In fact, 85 percent of
    NCI's budget supports research at nearly 650 universities, hospitals,
    cancer centers, and other institutions in all 50 States. Because these
    centers are networked nationally, opportunities for collaborations are
    many--assuring wise and nonduplicative investment of scarce Federal
    dollars.
    ---------------------------------------------------------------------------
        \5\ National Cancer Institute 2007 Fact Book. U.S. Department of
    Health and Human Services, U.S. National Institutes of Health, 2007.
    ---------------------------------------------------------------------------
        In addition to conducting basic, clinical, and population research,
    the cancer centers are largely responsible for training the cancer
    workforce that will practice in the United States in the years to come.
    Much of this training is dependent on Federal dollars, via training
    grants and other funding from NCI. Sustained Federal support will
    significantly enhance the centers' ability to continue to train the
    next generation of cancer specialists--both researchers and providers
    of cancer care.
        By providing access to a wide array of expertise and programs
    specializing in prevention, diagnosis, and treatment of cancer, cancer
    centers play an important role in reducing the burden of cancer in
    their communities. The majority of the clinical trials of new
    interventions for cancer are carried out at the Nation's network of
    cancer centers.
        Beyond their healthcare and research roles, cancer centers are also
    reliable engines of economic activity for the Nation as a whole, and
    for the communities and regions that they serve. For every $1 spent on
    biomedical research, a national average of $2.21 in economic benefit
    results.\6\
    ---------------------------------------------------------------------------
        \6\ In Your Own Backyard: How NIH Funding Helps Your State's
    Economy, Families USA, June 2008
    ---------------------------------------------------------------------------
                ensuring the future of cancer care and research
        Because of an aging population, an increasing number of cancer
    survivors require ongoing monitoring and care from oncologists, and new
    therapies that tend to be complex and often extend life.
        Demand for oncology services is projected to increase 48 percent by
    2020. However, the supply of oncologists expected to increase by only
    20 percent and 54 percent of currently practicing oncologists will be
    of retirement age within that timeframe. Also, alarmingly, there has
    been essentially no growth over the past decade in the number of
    medical residents electing to train on a path toward oncology as a
    specialty.\7\
    ---------------------------------------------------------------------------
        \7\ Forecasting the Supply of and Demand for Oncologists: A Report
    to the American Society of Clinical Oncology (ASCO) from the AAMC
    Center for Workforce Studies. American Society of Clinical Oncology,
    2007.
    ---------------------------------------------------------------------------
        Cancer physicians--while essential--are only one part of the
    oncology workforce that is in danger of being stretched to the breaking
    point. The Health Resources and Services Administration predicted that
    by 2020, more than 1 million nursing positions will go unfilled, and a
    2002 survey by the Southern Regional Board of Education projected a 12
    percent shortage of nurse educators by last year.\8\
    ---------------------------------------------------------------------------
        \8\ ONS: Ready to Collaborate with Other Policymakers to Ensure
    Future of Quality Cancer Care, Oncology Times, August 25, 2007; (29):
    8-9.
    ---------------------------------------------------------------------------
        Without immediate action, these predicted shortages will prove
    disastrous for the state of cancer care in the United States. The
    discrepancy between supply and demand for oncologists will amount to a
    shortage of 9.4 to 15.1 million visits, or a shortage of 2,550 to 4,080
    oncologists. The Department of Health and Human Services projects that
    today's 10-percent vacancy rate in registered nursing positions will
    grow to 36 percent, representing more than 1 million unfilled jobs by
    2020.
        Greater Federal support for training oncology physicians, nurses,
    and other professionals who treat cancer must be enacted to prevent a
    disaster within our healthcare system when demand for oncology services
    far outstrips the system's ability to provide adequate care for all.
                 americans support federal funding for research
        The research community has long understood the obstacles that are
    facing cancer research. Though the nuances of R01 grants and oncology
    workforce training may not be well understood by the average American,
    the people of the United States believe in supporting the disparate
    activities that make up America's biomedical research infrastructure.
        In a 2007 Research!America poll, 91 percent of those surveyed
    believed it was somewhat or very important for policymakers to create
    more incentives to encourage individuals to pursue careers as nurses,
    while 89 percent believed the same for encouraging careers as
    physicians. Forty-seven percent of those surveyed agreed that he United
    States must increase investment in NIH to ensure our future health and
    economic security, and 54 percent favored annual 6.7 percent increases
    in funding for NIH in 2008, 2009, and 2010. An overwhelming majority--
    70 percent--agreed that the United States is losing its global
    competitive edge in science, technology, and innovation.
        We encourage our Members of Congress to respond to the concerns of
    the American people by enhancing support for biomedical research that
    will lead to improved health for everyone in the United States and
    around the world.
                                   conclusion
        These are exciting times in science and, particularly, in cancer
    research. The AACI cancer center network is unrivaled in its pursuit of
    excellence, and place the highest priority on affording all Americans
    access to that care, including novel treatments and clinical trials. It
    is through the power of collaborative innovation that we will
    accelerate progress toward a future without cancer, and research
    funding through the NIH and NCI is essential to achieving our goals.
                                     ______

     Prepared Statement of the American Association of Colleges of Nursing
        The American Association of Colleges of Nursing (AACN) respectfully
    submits this statement highlighting funding priorities for nursing
    education and research programs in fiscal year 2010. AACN represents
    more than 640 schools of nursing at public and private institutions
    with baccalaureate and graduate nursing programs that include more than
    270,000 students and 13,000 faculty members. These institutions educate
    almost half of our Nation's Registered Nurses (RNs) and all of the
    nurse faculty and researchers. Many of these nursing schools sponsor
    intensive research programs and training activities that are funded by
    the National Institute of Nursing Research (NINR).
                        the nationwide nursing shortage
        The United States is in the midst of a nursing shortage that has
    expanded over the last decade. The current economic downturn has led to
    a false impression that the nursing shortage is ``easing'' in some
    parts of the country because hospitals are enacting hiring freezes and
    nurses are choosing to delay retirement. However, this trend is only
    temporary. More positions continue to open for RNs across the country,
    and the shortage is projected to intensify as the baby-boomer
    population ages and the need for healthcare grows. The U.S. Bureau of
    Labor Statistics (BLS) recently reported that the healthcare sector of
    the economy is continuing to expand, despite significant job losses in
    nearly all other major industries. Hospitals, long-term care
    facilities, and other ambulatory care settings added 27,000 new jobs in
    February 2009, a month when 681,000 jobs were eliminated across the
    country. As the largest segment of the healthcare workforce, RNs likely
    will be recruited to fill many of these new positions. Moreover,
    according to the latest projections from the BLS, more than 1 million
    new and replacement nurses will be needed by 2016. Unless we act now,
    this shortage will further jeopardize patient access to quality care.
        Nursing and economic research clearly indicate that today's
    shortage is far worse than those of the past. The current supply and
    demand for nurses demonstrates two distinct challenges. First, due to
    the present and looming demand for healthcare by American consumers,
    the supply is not growing at a pace that will adequately meet long-term
    needs, including the demand for primary care, which is often provided
    by Advanced Practice Registered Nurses (APRNs). This is further
    compounded by the number of nurses who will retire or leave the
    profession in the near future, ultimately reducing the nursing
    workforce. Second, the supply of nurses nationwide is stressed due to
    an ongoing shortage of nurse faculty. The nurse faculty shortage
    continues to inhibit nursing schools from educating the number of
    nurses needed to meet the demand. According to AACN, 49,948 qualified
    applicants were turned away from baccalaureate and graduate nursing
    programs in 2008 primarily due to a lack of faculty. Of those potential
    students, nearly 7,000 were students pursuing a master's or doctoral
    degree in nursing, which is the education level required to teach.
           nursing workforce development programs: a proven solution
        For nearly five decades, the Nursing Workforce Development Programs
    have supported hundreds of thousands of nurses and nursing students.
    The title VIII programs award grants to nursing education programs, as
    well as provide direct support to nurses and nursing students through
    loans, scholarships, traineeships, and programmatic grants.
        The Nursing Workforce Development Programs are effective and meet
    their authorized mission. In a 2009 survey by AACN, 1,501 title VIII
    student recipients reported that these programs played a critical role
    in funding their nursing education. An overwhelming number of
    respondents (92.7 percent), reported that title VIII paid for a portion
    of their tuition and, of those students, approximately 11 percent
    reported their tuition was paid in full. While millions of Americans
    are struggling during this economic downturn and thousands of students
    need to obtain student loans for their education, Federal support is
    greatly appreciated and needed. The nursing students responding to this
    study expressed overwhelming gratitude for the funding they receive
    through title VIII. Nursing remains an attractive and rewarding career
    with more than 135,000 current vacant positions, and according to the
    BLS, more than 587,000 new nursing positions will be needed by 2016.
    Providing support for title VIII is the key to filling these vacant
    positions and, in turn, improving healthcare quality.
        Over the last 45 years, Congress has used the title VIII
    authorities as a mechanism to address nursing shortages. When the need
    for nurses was great, higher funding levels were appropriated. During
    the nursing shortage of the 1970s, Congress provided $160.61 million to
    the title VIII programs in fiscal year 1973. Adjusting for inflation to
    address the 36-year difference, the fiscal year 2009 funding level of
    $171.03 million in 1973 dollars would be approximately $820 million
    today (see Figure 1). More recently, slow rising funding levels between
    fiscal year 2006 and fiscal year 2008 for title VIII, coupled with
    inflation and rising educational costs, have greatly decreased the
    purchasing power of these programs, resulting in a 43 percent decrease
    in the number of nurses supported by the programs (see Figure 2).

        AACN is delighted that President Obama has noted the need for
    increased title VIII funding in his fiscal year 2010 budget proposal.
    Therefore, AACN respectfully requests the subcommittee's support for
    the President's proposal of $263.4 million for title VIII Nursing
    Workforce Development Programs in fiscal year 2010, an additional $92
    million more than the fiscal year 2009 level. New monies would expand
    nursing education, recruitment, and retention efforts to help resolve
    all aspects contributing to the shortage.
            ninr: supporting health promotion and disease prevention
        As the scientific and research nucleus for nursing science, the
    NINR funds research that establishes the scientific basis for health
    promotion, disease prevention, and high-quality nursing care services
    to individuals, families, and populations. NINR is one of the 27
    Institutes and Centers at the National Institutes of Health (NIH).
    Often working collaboratively with physicians and other researchers,
    nurse scientists are vital in setting the national research agenda.
    While medical research focuses on curing diseases, nursing research is
    conducted to prevent disease. The four strategic areas of emphasis for
    research at NINR are:
      --Promoting health and preventing disease;
      --Improving quality of life;
      --Eliminating health disparities; and
      --Setting directions for end-of-life research.
        The science advanced at NINR is integral to the future of the
    Nation's healthcare system. With a renewed national priority on
    utilizing cost-effective treatment modalities and preventive
    interventions, NINR has developed research programs in these areas:
        Comparative Effectiveness Research.--Has been an NINR funding
    priority for many years. Comparative effectiveness research
    demonstrates how prevention strategies or interventions can impact
    system-wide savings. At a time when healthcare consumers and reformers
    are seeking quality care focused on prevention that is affordable and
    accessible by all, comparative effectiveness research is a critical
    area of inquiry.
        Promoting Health and Preventing Disease.--Is vital considering that
    more than 1.7 million Americans die each year from chronic diseases.
    Nurse researchers focus on investigating wellness strategies to prevent
    these chronic diseases. A healthcare system which promotes prevention
    promises to be a major focus of health reform, and NINR is a leader in
    funding scientific research to discover optimal prevention methods.
        NINR's fiscal year 2009 funding level of $141.88 million is
    approximately 0.47 percent of the overall $30.03 billion NIH budget
    (see Figure 3). Spending for nursing research is a modest amount
    relative to the allocations for other health science institutes and for
    major disease category funding. For NINR to adequately continue and
    further its mission, the Institute must receive additional funding.
    Cuts in funding have impeded the Institute from supporting larger
    comprehensive studies needed to advance nursing science and improve the
    quality of patient care.

        Therefore, AACN respectfully requests $178 million for NINR, an
    additional $36.12 million more than the fiscal year 2009 level.
    Considering that NINR presently allocates 7 percent of its budget to
    training that helps develop the pool of nurse researchers, additional
    funding would support NINR's efforts to prepare faculty researchers
    needed to educate new nurses.
     the capacity for nursing students and faculty program, section 804 of
       the higher education opportunity act of 2008 (public law 110-315)
        According to AACN (2009), the major barriers to increasing student
    capacity in nursing schools are insufficient numbers of faculty,
    admission seats, clinical sites, classroom space, clinical preceptors,
    and budget constraints. The Capacity for Nursing Students and Faculty
    Program, a recently passed section of the Higher Education Opportunity
    Act of 2008, offers capitation grants (formula grants based on the
    number of students enrolled/or matriculated) to nursing schools
    allowing them to increase the number of students. AACN respectfully
    requests $50 million for this program in fiscal year 2010.
                                   conclusion
        AACN acknowledges the fiscal challenges within which the
    subcommittee and the entire Congress must work. However, the title VIII
    authorities provide a dedicated, long-term vision for educating the new
    nursing workforce and the next cadre of nurse faculty. NINR invests in
    developing the scientific basis for quality nursing care. The Capacity
    for Nursing Students and Faculty Program will allow schools to increase
    student capacity. To be effective these programs must receive
    additional funding. AACN respectfully requests $263.4 million for title
    VIII programs, $178 million for NINR, and $50 million for the Capacity
    for Nursing Students and Faculty Program in fiscal year 2010.
    Additional funding for these programs will assist schools of nursing to
    expand their educational and research programs, educate more nurse
    faculty, increase the number of practicing RNs, and ultimately improve
    the patient care provided in our healthcare system.
                                     ______

         Prepared Statement of the American Association of Colleges of
                              Osteopathic Medicine
        On behalf of the American Association of Colleges of Osteopathic
    Medicine (AACOM), I am submitting this testimony in support of
    increased funding in fiscal year 2010 for the title VII health
    professions education programs, the National Health Service Corps
    (NHSC), the National Institutes of Health (NIH), and the Agency for
    Healthcare Research and Quality (AHRQ). AACOM represents the
    administrations, faculty, and students of the Nation's 25 colleges of
    osteopathic medicine and three branch campuses that offer the doctor of
    osteopathic medicine degree. Today, more than 15,500 students are
    enrolled in osteopathic medical schools. Nearly 1 in 5 U.S. medical
    students is training to be an osteopathic physician, a ratio that is
    expected to grow to 1 in 4 by 2019.
                                   title vii
        The health professions education programs, authorized under title
    VII of the Public Health Service Act and administered through the
    Health Resources and Services Administration (HRSA), support the
    training and education of health practitioners to enhance the supply,
    diversity, and distribution of the healthcare workforce, filling the
    gaps in the supply of health professionals not met by traditional
    market forces. Title VII and title VIII nurse education programs are
    the only Federal programs designed to train clinicians in
    interdisciplinary settings to meet the needs of special and underserved
    populations, as well as increase minority representation in the
    healthcare workforce.
        According to HRSA, an additional 30,000 health practitioners are
    needed to alleviate existing health professional shortages. Combined
    with faculty shortages across health professions disciplines, racial
    and ethnic disparities in healthcare, and a growing, aging population,
    these needs strain an already fragile healthcare system. AACOM
    recommends $330 million in fiscal year 2010 for the title VII programs.
    Investment in these programs, including the Training in Primary Care
    Medicine and Dentistry Program, the Health Careers Opportunity Program,
    and the Centers of Excellence, is necessary to address the primary care
    workforce shortage. Such an investment will help sustain the health
    workforce expansion supported by the American Recovery and Reinvestment
    Act (ARRA) and restore funding to critical programs that suffered
    drastic funding reductions in fiscal year 2006 and remain well below
    fiscal year 2005 levels.
        AACOM is pleased that President Obama requested considerable
    increases in the following title VII programs: Training in Primary Care
    Medicine and Dentistry ($56.4 million requested/16.5 percent increase);
    Centers of Excellence ($24.6 million requested/19.4 percent increase);
    and Health Careers Opportunity Program ($22.1 million requested/15.7
    percent increase).
                                      nhsc
        Approximately 50 million Americans live in communities with a
    shortage of health professionals, lacking adequate access to primary
    care. Through scholarships and loan repayment, HRSA's NHSC supports the
    recruitment and retention of primary care clinicians to practice in
    underserved communities. The NHSC is comprised of more than 4,000
    clinicians, with more than half working in community health centers.
    Growth in HRSA's Health Center Program must be complemented with
    increases in the recruitment and retention of primary care clinicians
    to ensure adequate staffing. ARRA funding for the NHSC is vital in this
    regard, and additional investment will be necessary to sustain the
    progress once the ARRA funding period ends. AACOM recommends $235
    million in fiscal year 2010 for NHSC, the amount authorized under the
    Health Care Safety Net Amendments of 2002.
        AACOM notes that President Obama requested significant increases
    for NHSC field placement ($46 million requested/6 percent increase) and
    recruitment ($123 million requested/29.5 percent increase).
                                      nih
        Research funded by the NIH leads to important medical discoveries
    regarding the causes, treatments, and cures for common and rare
    diseases as well as disease prevention. These efforts improve our
    Nation's health and save lives. The NIH funding under the ARRA will
    produce more high-quality research. To seize the momentum created by
    the ARRA and maintain a robust research agenda, further investment will
    be needed. AACOM recommends $33.35 billion in fiscal year 2010 for the
    NIH.
        In today's increasingly demanding and evolving medical curriculum,
    there is a critical need for more research geared toward evidence-based
    osteopathic medicine. AACOM believes that it is vitally important to
    maintain and increase funding for biomedical and clinical research in a
    variety of areas related to osteopathic principles and practice,
    including osteopathic manipulative medicine and comparative
    effectiveness. In this regard, AACOM encourages support for the NIH's
    National Center for Complementary and Alternative Medicine (NCCAM) to
    continue fulfilling this essential research role.
        AACOM appreciates President Obama requesting increases for NIH ($31
    billion requested/1.45 percent increase) and NCCAM ($127 million
    requested/1.6 percent increase).
                                      ahrq
        AHRQ supports research to improve healthcare quality, reduce costs,
    advance patient safety, decrease medical errors, and broaden access to
    essential services. AHRQ plays an important role in producing the
    evidence base needed to improve our Nation's health and healthcare. The
    incremental increases for AHRQ's Effective Health Care Program in
    recent years, as well as the funding provided to AHRQ in the ARRA, will
    help AHRQ generate more comparative effectiveness research and expand
    the infrastructure needed to increase capacity to produce this
    evidence. More investment is needed, however, to fulfill AHRQ's mission
    and broader research agenda. AACOM recommends $405 million in fiscal
    year 2010 for AHRQ. This investment will preserve AHRQ's current
    programs while helping to restore its critical healthcare safety,
    quality, and efficiency initiatives.
        AACOM greatly appreciates the support of the subcommittee for these
    funding priorities in an ever increasing competitive environment and is
    grateful for the opportunity to submit its views. AACOM looks forward
    to continuing to work with the subcommittee on these important matters.
                                     ______

     Prepared Statement of the American Association of Colleges of Pharmacy
        The American Association of Colleges of Pharmacy (AACP) and its
    member colleges and schools of pharmacy appreciate the continued
    support of the Senate Appropriations Subcommittee on Labor, Health and
    Human Services, and Education, and Related Agencies. Our Nation's 111
    accredited colleges and schools of pharmacy are engaged in a wide-range
    of programs supported by grants and funding administered through the
    agencies of the Department of Health and Human Services (HHS) and the
    Department of Education. We also understand the difficult task you face
    annually in your deliberations to do the most good for the nation and
    remain fiscally responsible to the same. AACP respectfully offers the
    following recommendations for your consideration as you undertake your
    deliberations.
    department of health and human services supported programs at colleges
                            and schools of pharmacy
    Agency for Healthcare Research and Quality (AHRQ)
        AACP supports the Friends of AHRQ recommendation of $405 million
    for AHRQ programs in fiscal year 2010.
        Pharmacy faculty are strong partners with AHRQ. Academic pharmacy
    researchers are working to develop a sustainable health services
    research effort among faculty with AHRQ grant support. As partners in
    the AHRQ Effective Healthcare programs (CERTs, DeCIDE), pharmacy
    faculty researchers improve the effectiveness of healthcare services.
    Some of this research will take place through the development of
    practice-based research networks focused on improving the medication
    use process.
      --Last fall, AHRQ expanded its Centers for Education and Research on
            Therapeutics (CERTs) program by awarding $41.6 million over the
            next 4 years for a new coordinating center, 10 research centers
            and four new centers receiving first-time funding. The
            University of Illinois at Chicago College of Pharmacy joins the
            13 CERTs program centers in efforts to conduct research and
            provide education that advances the optimal use of
            therapeutics.
        http://www.aacp.org/news/academicpharmnow/Documents/
            MarApr%202008%20APN.pdf
      --Pharmacy faculty researchers, supported by AHRQ grant HS016097,
            determined that children who are prescribed medications related
            to their diagnosis of attention deficit/hyperactivity disorder
            were not at increased risk for hospitalization for cardiac
            events. The results of this research will be presented in a web
            conference sponsored by AHRQ and APhA on May 1, 2009.
    Centers for Disease Control and Prevention (CDC)
        AACP supports the CDC Coalition recommendation of $8.6 billion for
    CDC core programs in fiscal year 2010.
        The educational outcomes of a pharmacist's education include those
    related to public health. When in community-based positions,
    pharmacists are frequently providers of first contact. The opportunity
    to identify potential public health threats through regular interaction
    with patients provides public health agencies such as the CDC with on-
    the-ground epidemiologists. Pharmacists support the public health
    system through the risk identification of patients seeking medications
    associated with preventing and treating travel-related illnesses.
    Pharmacy faculty are engaged in CDC-supported research in areas such as
    immunization delivery, integration of pharmacogenetics in the pharmacy
    curriculum and inclusion of pharmacists in emergency preparedness.
    Information from the National Center for Health Statistics (NCHS) is
    essential for faculty engaged in health services research and for the
    professional education of the pharmacist.
      --Grace Kuo, CDC-supported member of the faculty at the University of
            California, San Diego, is engaged in research aimed at
            improving the safety of medication use in primary care
            settings.
      --Jeanine Mount, CDC-supported member of the faculty at the
            University of Wisconsin, is engaged in research to determine
            how pharmacists can be better utilized in increase the
            vaccination rates across our Nation.
    Health Resources and Services Administration (HRSA)
        AACP supports the Friends of HRSA recommendation of $8.5 billion.
        HRSA is a Federal agency with a wide-range of policy and service
    components. Faculty at colleges and schools of pharmacy are integral to
    the success of many of these. Colleges and schools of pharmacy are the
    administrative units for interprofessional and community-based linkages
    programs including geriatric education centers and area health
    education centers. Pharmacy faculty are supported in their research
    efforts regarding rural health issues through the Office of Rural
    Health Policy. Pharmacy students benefit from diversity program funding
    including Scholarships for Disadvantaged Students.
                        office of pharmacy affairs (opa)
        AACP recommends a program funding of $5 million for fiscal year
    2010 for OPA.
        AACP member institutions are actively engaged in OPA efforts to
    improve the quality of care for patients in federally qualified health
    centers and entities eligible to participate in the 340B drug discount
    program. The success of the HRSA Patient Safety and Clinical Pharmacy
    Collaborative is a direct result of past OPA actions linking colleges
    and schools of pharmacy with federally qualified health centers
    (www.hrsa.gov/patientsafety). The result of these links has been the
    establishment of medical homes that improve health outcomes for
    underserved and disadvantaged patients through the integration of
    clinical pharmacy services. The Office of Pharmacy Affairs would
    benefit from a direct line-item appropriation so that public-private
    partnerships aimed at improving the quality of care provided at
    federally qualified health centers can be sustained and expanded.
                             poison control centers
        Colleges and schools of pharmacy are supported by HRSA grant
    funding for the operation of 9 of the 42 poison control centers
    administered by HRSA.
      --Jill E. Michels, faculty member from the University of South
            Carolina--South Carolina College of Pharmacy (USC), and the
            Palmetto Poison Center (PPC) were awarded a $310,000 grant from
            HRSA. The PPC is housed at the College of Pharmacy and serves
            all 46 counties in South Carolina receiving more than 37,000
            calls per year for information and advice. A recent USC study
            found that for every $1 spent on the Palmetto Poison Center,
            more than $7 was saved in unnecessary healthcare costs,
            including emergency room and physician visits, ambulance
            services, and unnecessary medical treatments. http://
            poison.sc.edu/about.html
                      bureau of health professions (bhpr)
        AACP supports the Health Professions and Nursing Education
    Coalition (HPNEC) recommendation of $550 million for title VII and VIII
    programs in fiscal year 2010.
        AACP member institutions are active participants in BHPr programs.
    Two colleges of pharmacy are current grantees in the Centers of
    Excellence program (Xavier University--Louisiana and the University of
    Montana) which focuses on increasing the number of underserved
    individuals attending health professions institutions. Colleges and
    schools of pharmacy are also part of title VII interprofessional and
    community-based linkages programs including Geriatric Education Centers
    and Area Health Education Centers. These programs are essential for
    creating the educational approaches that align with the Institute of
    Medicine's recommendations for improving quality through team-based,
    patient-centered care.
                        office of telehealth advancement
        Technology is an important component for improving healthcare
    quality and maintaining or increasing access to care. Colleges and
    schools of pharmacy utilize technology to increase the reach of
    education to aspiring and current professionals.
      --Massachusetts College of Pharmacy and Health Sciences--Worcester
            Campus Distance Learning Initiative--Phase II.--Grant support
            for this program will allow the expansion of health profession
            education programs throughout Massachusetts and New Hampshire.
            http://hrsa.gov/telehealth/granteedirectory/overview_ma.htm
      --North Dakota State University College of Pharmacy, Nursing, and
            Allied Sciences uses grant funding to maintain access to
            pharmacy services in rural, underserved areas of North Dakota.
            This program helps more than 40,000 rural citizens maintain
            access to pharmacy services and also supports rural hospital
            pharmacies. http://hrsa.gov/telehealth/granteedirectory/
            overview_nd.htm
                       food and drug administration (fda)
        AACP recommends a funding level of $3 billion for FDA programs in
    fiscal year 2010.
        Academic pharmacy is working with the FDA to fulfill its strategic
    goals and the responsibilities assigned to the agency through the Food
    and Drug Administration Amendments Act. The FDA sees the colleges and
    schools of pharmacy as essential partners in assuring the public has
    access to a healthcare professional well versed in the science of
    safety.
      --Carole L. Kimberlin, a professor, and Almut G. Winterstein, an
            assistant professor at the University of Florida College of
            Pharmacy Department of Pharmaceutical Outcomes and Policy,
            received a 1-year $184,229 award from the FDA to conduct an
            evaluation of Consumer Medication Information leaflets on
            selected prescription medications from community pharmacies
            throughout the United States.
      --Thomas C. Dowling's research, ``Evaluation of Biopharmaceutics
            Classification System Class 3 Drugs for Possible Biowaivers,''
            is supported by an FDA grant.
      --The FDA-supported National Institute of Pharmaceutical Technology
            and Education is funding research at the University of
            Connecticut focused on the development of freeze-dried
            products.
                      national institutes of health (nih)
        AACP supports the Ad Hoc Group for Medical Research recommendation
    of $32.4 billion for fiscal year 2010.
        Pharmacy faculty are supported in their research by nearly every
    Institute at the NIH. The NIH-supported research at AACP member
    institutions spans theresearch spectrum from the creation of new
    knowledge through the translation of that new knowledge to providers
    and patients. In 2008, pharmacy faculty researchers received more than
    $260 million in grant support from the NIH.
      --Researchers at the University of Illinois at Chicago College of
            pharmacy have received a $1.7 million 5-year Federal grant to
            develop a new approach to treat brain tumors. The novel
            approach stabilizes the drug and provides better control of the
            time and location of its activity, thereby reducing its side
            effects.
      --University of Nebraska Medical Center (UNMC) received $10.6 million
            from the National Center for Research Resources (NCRR) to
            research nanomedicine, drug delivery, therapeutics, and
            diagnostics. UNMC researcher, Dr. Alexander V. Kabanov, is the
            principal investigator on the $10.6 million COBRE (Centers for
            Biomedical Research Excellence) grant, which will be awarded by
            the NIH/NCRR over the next 5 years.
      --Dr. Maria Croyle, associate professor of pharmaceutics at The
            University of Texas at Austin College of Pharmacy, has received
            $2.6 million from NIH to develop a vaccine against Ebola virus
            infection.
      --As part of NIH funding for the new NIH Roadmap Epigenomics Program,
            Dr. Rihe Liu, associate professor at the University of North
            Carolina at Chapel Hill Eshelman School of Pharmacy, received a
            technology development grant to support the advancement of
            innovative technologies that have the potential to transform
            the way that epigenomics research can be performed in the
            future.
      --A project funded by the National Institute of General Medical
            Sciences takes computer-aided drug design to the next level
            with the help of a University of Michigan College of Pharmacy
            professor.
      --Fourteen additional universities were awarded the Clinical and
            Translational Science Award in May 2008. Five colleges of
            pharmacy are included in this group and will play significant
            collaborative roles with the new consortium members as the NIH
            provides $533 million over 5 years to help enable researchers
            to provide new treatments more efficiently and effectively to
            patients.
      --Dr. Laurence H. Hurley, professor of pharmaceutical sciences at The
            University of Arizona College of Pharmacy, is 1 of 38
            scientists to receive the 2009 NIH EUREKA grant.
     department of education supported programs at colleges and schools of
                                    pharmacy
        AACP supports the recommendation of the Student Aid Alliance that
    the:
      --Perkins Loan Program Federal Capital Contribution should be
            increased to the newly reauthorized level of $300 million and
            loan cancellations should be increased to $125 million.
      --Pell Grant maximum be increased to $5,500.
      --Gaining Early Awareness and Readiness for Undergraduate Programs
            (GEAR UP) should be increased to the authorized level of $400
            million.
      --Graduate level programs should be increased to $77 million.
        AACP recommends a funding level of $140 million for the Fund for
    the Improvement of Post Secondary Education (FIPSE).
        The Department of Education supports the education of healthcare
    professionals by:
      --assuring access to education through student financial aid
            programs;
      --supporting educational research allows faculty to determine
            improvements in educational approaches; and
      --maintaining the quality of higher education through the approval of
            accrediting agencies.
        AACP actively supports increased funding for undergraduate student
    financial assistance programs. Admission to into the pharmacy
    professional degree program requires at least 2 years of undergraduate
    preparation. Student financial assistance programs are essential to
    assuring colleges and schools of pharmacy are accessible to qualified
    students. Likewise, financial assistance programs that support graduate
    education are an important component of creating the next generation of
    scientists and educators that both our Nation and higher education
    depend on.
                                     ______

       Prepared Statement of the American Association for Cancer Research
        The American Association for Cancer Research (AACR) recognizes and
    expresses its thanks to the United States Congress for its longstanding
    support and commitment to funding cancer research. The recent large-
    scale investment in research through the American Recovery and
    Reinvestment Act (ARRA) and the fiscal year 2009 budget will support
    current projects and provide for new efforts in the fight against
    cancer. These new efforts promise to yield innovative and potentially
    breakthrough approaches to understanding, preventing, treating, and
    ultimately curing cancer. The full potential, however, will not be
    fully realized in a short 1- or 2-year period. Sustained, stable
    funding through regular appropriations will be necessary to allow
    researchers to make the key investments that will leverage the ARRA
    funds so that they both create jobs today and save lives tomorrow.
        Unquestionably, the Nation's investment in cancer research is
    having a remarkable impact. Cancer deaths in the United States have
    declined in recent years. This progress occurred in spite of an aging
    population and the fact that more than three-quarters of all cancers
    are diagnosed in individuals aged 55 and older. Yet this good news will
    not continue without stable and sustained Federal funding for critical
    cancer research priorities.
        AACR urges the United States House of Representatives to support
    President Obama's vision for doubling cancer research funding over the
    next 5 years and strongly support other biomedical research funding at
    the National Institutes of Health (NIH). AACR supports the $6 billion
    for cancer research highlighted in the President's fiscal year 2010
    budget outline, which would be best allocated to the National Cancer
    Institute (NCI). The AACR also supports the biomedical community's
    recommendation of a 7 percent increase for the NIH, which, when
    combined with President Obama's vision for cancer research, would fund
    NIH at a level of $33.3 billion in fiscal year 2010.
                 aacr: fostering a century of research progress
        The American Association for Cancer Research has been moving cancer
    research forward since its founding in 1907. Celebrating its 100th
    annual meeting, the AACR and its more than 28,000 members worldwide
    strive tirelessly to carry out its important mission to prevent and
    cure cancer through research, education, and communication. It does so
    by:
      --fostering research in cancer and related biomedical science;
      --accelerating the dissemination of new research findings among
            scientists and others dedicated to the conquest of cancer;
      --promoting science education and training; and
      --advancing the understanding of cancer etiology, prevention,
            diagnosis, and treatment throughout the world.
                     facing an impending cancer ``tsunami''
        Over the past 100 years, enormous progress has been made toward the
    conquest of the Nation's second most lethal disease (after heart
    disease). Thanks to discoveries and developments in prevention, early
    detection, and more effective treatments, many of the more than 200
    diseases called cancer have been cured or converted into manageable
    chronic conditions while preserving quality of life. The 5-year
    survival rate for all cancers has improved over the past 30 years to
    more than 65 percent. The completion of the doubling of the NIH budget
    in 2003 is bearing fruit as many new and promising discoveries are
    unearthed and their potential realized. However, there is much left to
    be done, especially for the most lethal and rarer forms of the disease.
        We recognize that the underlying causes of the disease and its
    incidence have not been significantly altered. The fact remains that
    men have a 1 in 2 lifetime risk of developing cancer, while women have
    a 1 in 3 lifetime risk. The leading cancer sites in men are the
    prostate, lung and bronchus, and colon and rectum. For women, the
    leading cancer sites are breast, lung and bronchus, and colon and
    rectum. And cancer still accounts for 1 in 4 deaths, with more than
    half a million people expected to die from their cancer in 2009. Age is
    a major risk factor--this Nation faces a virtual ``cancer tsunami'' as
    the baby boomer generation reaches age 65 in 2011. A renewed commitment
    to progress in cancer research through leadership and resources will be
    essential to avoid this cancer crisis.
               blueprint for progress: nci's strategic objectives
        Basic, translational, and clinical cancer research in this country
    is conducted primarily through three venues--Government, academia and
    the nonprofit sector, and the pharmaceutical/biotechnology industry.
    The Congress provides the appropriations for the National Institutes of
    Health and the NCI through which most of the Government's research on
    cancer is conducted. The NCI has developed documents and processes that
    describe and guide its priorities--established with extensive community
    input--for the use of these finite resources. ``The NCI Strategic Plan
    for Leading the Nation'' and ``The Nation's Investment in Cancer
    Research: An Annual Plan and Budget Proposal fiscal year 2010'' are the
    recognized professional blueprints for what needs to be done to
    accelerate progress against cancer.
        AACR and many in the cancer research community concur that if the
    NCI receives the increased investment of $2.1 billion as proposed for
    fiscal year 2010, the Director's proposed budget will enable the NCI to
    rebuild America's research infrastructure capacity and accelerate
    research progress in critical priority areas.
                      federal investment for local benefit
        More than half of the NCI budget is allocated to research project
    grants that are awarded to outside scientists who work at local
    hospitals and universities throughout the country. More than 6,500
    research grants are funded at more than 150 cancer centers and
    specialized research facilities located in 49 States. More than half
    the States receive more than $15 million in grants and contracts to
    institutions located within their borders. This Federal investment
    provides needed economic stimulus to local economies: on average, each
    dollar of NIH funding generated more than twice as much in State
    economic output in fiscal year 2007. Many AACR member scientists across
    the Nation are engaged in this rewarding work, and many have had their
    long-term research jeopardized by grant reductions caused by the flat
    and declining overall funding for the NCI since 2003. The recent
    increase in fiscal year 2009 appropriations and the funds from the
    American Recovery and Reinvestment Act of 2009 will help to revitalize
    America's research infrastructure; however, sustained and stable
    funding is critical to reap the benefits of this investment. Thus, the
    AACR supports the request in the President's budget proposal for $6
    billion in funding for cancer research in fiscal year 2010 and his
    commitment to double funding for cancer research over the next 5 years
    and, thus, recommends a 20 percent increase in funding for the NCI to
    enable it to continue and expand its important work.
               understanding the causes and mechanisms of cancer
        Basic research into the causes and mechanisms of cancer is at the
    heart of what the NCI and many of AACR's member scientists do. The
    focus of this research includes: investigating the underlying basis of
    the full spectrum of genetic susceptibility to cancer; identifying the
    influence of the macroenvironment (tumor level) and microenvironment
    (tissue level) on cancer initiation and progression; understanding the
    behavioral, environmental, genetic, and epigenetic causes of cancer and
    their interactions; developing and applying emerging technologies to
    expand our knowledge of risk factors and biologic mechanisms of cancer;
    and elucidating the relationship between cancer and other human
    diseases.
        Basic research is the engine that drives scientific progress. The
    outcomes from this fundamental basic research--including laboratory and
    animal research in addition to population studies and the deployment of
    state-of-the-art technologies--will inform and drive the cancer
    research enterprise in ways and directions that will lead to
    unparalleled progress in the search for cures.
                 developing effective and efficient treatments
        The future of cancer care is all about developing individualized
    therapies tailored to the specific characteristics of a patient's
    cancer. The NCI research in this area concentrates on: identifying the
    determinants of metastatic behavior; validating cancer biomarkers for
    prognosis, metastasis, treatment response, and progression;
    accelerating the identification and validation of potential cancer
    molecular targets; minimizing the toxicities of cancer therapy; and
    integrating the clinical trial infrastructure for speed and efficiency.
    The completion of the Human Genome Project has opened the door to the
    promise of personalized medicine.
     training and career development for the next generation of researchers
        Of critical importance to the viability of the long-term cancer
    research enterprise is supporting, fostering, and mentoring the next
    generation of investigators. The NCI historically devotes approximately
    4 percent of its budget to multiple strategies to training and career
    development, including sponsored traineeships, a Medical Scientist
    Training Program, special set-aside grant programs and bridge grants
    for early career cancer investigators. Increased funding for these
    foundational opportunities is essential to retain the scientific
    workforce that is needed to continue the fight against cancer.
                 aacr's initiatives augment support for the nci
        The NCI is not working alone or in isolation in any of these key
    areas. NCI research scientists reach out to other organizations to
    further their work. The AACR is engaged in scores of initiatives that
    strengthen, support, and facilitate the work of the NCI. Just a few of
    AACR's contributions include:
      --sponsoring the largest meeting of cancer researchers in the world,
            with more than 14,000 scientists, where 6,000 scientific
            abstracts featuring the latest basic, translational, and
            clinical scientific advances are presented;
      --publishing more than 3,400 original research articles each year in
            six prestigious peer-reviewed scientific journals, including
            cancer research, the most frequently cited cancer journal;
      --sponsoring the annual International Conference on Frontiers of
            Cancer Prevention Research, the largest such prevention meeting
            of its kind in the world;
      --supporting the work of its Chemistry in Cancer Research Working
            Group;
      --convening an AACR-FDA-NCI Think Tank on Clinical Biomarkers;
      --hosting, with NCI, the Molecular Targets and Cancer Therapeutics
            Conference;
      --sponsoring and supporting a Minorities in Cancer Research Council
            and a Women in Cancer Research Council;
      --Conducting the scientific review and grants administration for the
            more than $100 million donated to Stand Up To Cancer;
      --raising and distributing more than $5 million in awards and
            research grants.
                stable, sustained increases in research funding
        Remarkable progress is being made in cancer research, but much more
    remains to be done. Cancer costs the Nation more than $219 billion in
    direct medical costs and lost productivity due to illness and premature
    death. Respected University of Chicago economists Kevin Murphy and
    Robert Topel have estimated that even a modest one percent reduction in
    mortality from cancer would be worth nearly $500 billion in social
    value. Investments in cancer research stimulate the local economy today
    have huge potential returns in the future. Thanks to successful past
    investments, promising research opportunities abound and must not be
    lost. To maintain our research momentum, the AACR urges the United
    States House of Representatives to support a budget of $33.3 billion
    for the NIH, including $6 billion for the NCI.
                                     ______

     Letter From the American Association of Colleges for Teacher Education
                                                        April 30, 2009.
    Hon. Tom Harkin,
    Chairman, Subcommittee on Labor, Health and Human Services, and
            Education, and Related Agencies, Washington, DC.
        Dear Chairman Harkin: I want to extend my appreciation to you and
    your colleagues in Congress for your support of Federal education
    programs. Your commitment makes a significant difference for the
    education of our millions of PK-12 and postsecondary students.
        As you and your colleagues begin the fiscal year 2010
    appropriations process, the American Association of Colleges for
    Teacher Education (AACTE) urges you to increase the Federal
    Government's investment in the preparation of professional educators.
    While there are significant funds behind title II of the No Child Left
    Behind Act in the Improving Teacher Quality State Grants, the vast
    majority of these funds, and other funds in title II, go towards class
    size reduction and the professional development of practicing teachers.
    Equally important, though, is the initial preparation of teachers and
    other school personnel. And, in this respect, the Federal Government's
    investment, until very recently, has declined over the years. As this
    Nation is in the midst of teacher retention and shortage crises, it is
    critical that the Government responds with a plan that provides for
    systemic change.
        There are several programs within the Department of Education
    intended to strengthen and improve educator recruitment and preparation
    efforts. We are working with program authorizers in Congress and staff
    within the agencies to ensure that these programs work in concert with
    each other. However, one of the key factors that prevents these
    programs from becoming levers for systemic change is their consistent
    underfunding. The cost of preparing school personnel is significant.
        The primary Federal program in this area is the Teacher Quality
    Partnership (TQP) Grants (title II, Higher Education Opportunity Act).
    During the reauthorization of the Higher Education Act we supported
    several changes to title II of the bill that have resulted in a much
    stronger TQP program. Under this program, these grants go to
    partnerships of institutions of higher education, high-need local
    educational agencies, and high-need K-12 schools to prepare teachers
    and other school personnel to effectively serve in the schools. The
    grants are particularly focused on strengthening the clinical component
    of preparation programs--research has shown that preservice clinical
    experiences are essential to preparing effective teachers and to
    teacher retention.
        Grants can be used to strengthen prebaccalaureate preparation
    programs and/or to develop 1-year master's degree level teaching
    residency programs. In exchange for receiving a living stipend during
    the residency, teachers would commit to teaching for at least 3 years
    in a shortage field in a high-need school. The residency programs are
    targeted to recruiting career-changers and recent college graduates. In
    these times of rising unemployment, these programs are ideal for those
    who have been laid off and are seeking a stable and rewarding new
    career. President Obama wrote the legislation for the teaching
    residency programs when he was a Senator on the HELP Committee. During
    his Presidential campaign and since his election he has stated that he
    wants to prepare 30,000 new educators through the residency programs.
        In order to meet that goal, and to provide sufficient support to
    the partnerships that carry out TQP Grants, we ask that you fund the
    TQP program at the $150 million level in fiscal year 2010. The TQP
    program received $50 million in fiscal year 2009, and $100 million in
    the stimulus package. This is a significant boost to the program which
    was funded in fiscal year 2008 at $33 million. The $150 million in
    fiscal year 2010 appropriations will maintain the current level of
    funding when the stimulus funding concludes.
        Below you will find AACTE's recommendations for funding additional
    programs in fiscal year 2010.
      --Fund Teachers for a Competitive Tomorrow at the $60 Million
            Level.--This program was authorized in the America Competes
            Act, and it is currently funded at $2.18 million. This program
            and the TQP program are the only two Federal education program
            directed targeted to higher-education-based educator
            preparation programs. With the teacher shortage and retention
            crisis acutely felt in the math and science teaching fields,
            this program is a crucial piece of the response to ameliorate
            the teacher shortage challenges. This competitive grant program
            helps higher education institutions build baccalaureate and
            master's degree programs that allow students to major in STEM
            fields while working toward teacher certification.
      --Fund the Transition to Teaching program at the $60 Million Level.--
            This program, authorized in title II of the No Child Left
            Behind Act at the $150 million level and currently funded at
            $43.7 million, supports the development of teacher preparation
            programs suited for career-changers and others who enter
            teaching through nontraditional routes. Higher education
            institutions and other entities have used funds from this
            program to develop innovative preparation programs that
            accommodate the needs of a diverse educator candidate pool
            while ensuring that candidates are prepared to teach in today's
            K-12 classrooms.
      --Fund the Troops-to-Teachers program at the $25 Million Level.--Like
            Transition to Teaching, this program aims to attract teachers
            from another profession into the classroom. Troops-to-Teachers
            has been very successful at recruiting retired military into
            the teaching profession. By funding the program at $25 million,
            this would almost double the Government's investment in the
            program (currently at $14.4 million) during a time in which
            there is higher military interest in entering the K-12 teaching
            ranks.
      --Fund the IDEA Personnel Preparation Program at the $120 Million
            Level.--Currently funded at $90.65 million, this program
            provides essential funds to prepare and develop special
            educators. Special education teachers, much like math and
            science teachers, are in high demand in the K-12 schools with
            the shortage being significant. With the wide breadth and
            increasing number of special need students there needs to be an
            adequate supply of teachers who can work with them to ensure
            student learning.
      --Fund the Centers for Excellence Program at the $20 Million Level.--
            This new program was authorized in title II of the Higher
            Education Opportunity Act and is currently unfunded. Grants
            would support the strengthening of educator preparation
            programs at institutions that serve historically under-
            represented populations.
      --Fund the Teach to Reach Grant Program at the $15 Million Level.--
            This new program was authorized in title II of the Higher
            Education Opportunity Act and is currently unfunded.
            Institutions of higher education would use grants to ensure
            that all of their teacher candidates were prepared to teach
            children with disabilities. Almost every K-12 classroom has
            students with learning, intellectual, and/or physical
            disabilities. It is critical that every teacher is prepared
            with instructional skills that will assure that every child has
            the opportunity to learn.
      --Fund the Graduate Fellowships To Prepare Faculty at Colleges of
            Education Program at the $15 Million Level.--This new program
            was authorized in title II of the Higher Education Opportunity
            Act and is currently unfunded. The current shortage of K-12
            teachers in the math, science, special education, and English
            language learners fields is directly correlated with the
            shortage of faculty at institutions of higher education who
            prepare teachers in these fields. This program would support
            doctoral students who intend to become faculty who prepare
            teachers in these shortage areas.
        The AACTE is a national voluntary association of higher education
    institutions and other organizations and is dedicated to ensuring the
    highest-quality preparation and continuing professional development for
    teachers and school leaders. Our overarching mission is to enhance PK-
    12 student learning. Collectively, the AACTE membership prepares more
    than two-thirds of the new teachers entering schools each year in the
    United States.
        Thank you for your consideration of the perspective of AACTE and
    its membership of close to 800 private, State, and municipal colleges
    and universities--large and small--located in every State, the District
    of Columbia, the Virgin Islands, Puerto Rico, and Guam.
                Sincerely,
                                     Sharon P. Robinson, Ed.D.,
                                                     President and CEO.
                                     ______

       Prepared Statement of the American Association for Dental Research
        The American Association for Dental Research (AADR) is a nonprofit
    organization with more than 4,000 individual members and 100
    institutional members within the United States. The AADR's mission is
    to advance research and increase knowledge for the improvement of oral
    health for all Americans.
        The AADR thanks the subcommittee for this opportunity to testify
    about the exciting advances in oral health science. Americans are
    living better and healthier lives into old age due to recent advances
    in healthcare, including dental care and oral health research, thanks
    to the efforts of the National Institute of Dental and Craniofacial
    Research (NIDCR). NIDCR was formed in 1948 by the National Institutes
    of Health (NIH). Its staff has conducted research, trained researchers,
    and disseminated health information to improve the health of Americans
    and make it possible for them to live longer and healthier lives.
        On February 17 of this year, President Barack Obama signed into law
    the $787 billion stimulus package known as the American Recovery and
    Reinvestment Act (ARRA). This legislation will provide NIH with $8.2
    billion to conduct additional scientific research. AADR members,
    researchers across the country, would like to thank the committee for
    its past support and in particular for the funds contained in the
    stimulus package. The past investment in NIH has paid a dividend to
    taxpayers in the form of improved oral health.
                               health disparities
        One very challenging issue we face in this country is health
    disparities. We must learn more about the causes of cultural inequality
    among individual members of society if we are to conduct more effective
    research.
        The NIDCR's mission is to train and engage as many young
    investigators as possible in oral health disparities research to
    develop various methods of research to eliminate these disparities.
    They hope that this will improve the oral, dental, and craniofacial
    health of diverse populations.
        Health disparities are the persistent gaps between the health
    status of minorities and nonminorities in the United States. Despite
    continued advances in healthcare and technology, racial and ethnic
    minorities continue to have higher rates of disease, disabilities, and
    premature death than nonminorities. African Americans, Hispanics/
    Latinos, American Indians and Alaska natives, Asian Americans, Native
    Hawaiians, and Pacific Islanders have higher rates of infant mortality,
    cardiovascular disease, diabetes, AIDS, and cancer, and lower rates of
    immunizations and cancer screening.
        There is debate about what causes health disparities between ethnic
    and racial groups. However, it is generally accepted that disparities
    can result from three main areas:
      --from the personal, socioeconomic, and environmental characteristics
            of different ethnic and racial groups;
      --from the barriers certain racial and ethnic groups encounter when
            trying to enter into the healthcare delivery system; and
      --from the quality of healthcare different ethnic and racial groups
            receive.
        These are all considered possible causes for disparities between
    racial and ethnic groups. However, most attention on the issue has been
    given to the health outcomes that result from differences in access to
    medical care among groups and the quality of care that various groups
    receive. Since many scientific discoveries do not reach all people,
    there are disparities in the health and healthcare among various groups
    in the United States. Even though data on racial and ethnic disparities
    are relatively widely available, data on socioeconomic healthcare
    disparities are collected less often.
        The Health Disparities Research Program responds to the growing
    awareness that, despite improvements in some oral health status
    indicators, the burden of disease is not evenly distributed across all
    segments of our society. The program supports research that explores
    the multiple and complex factors that may determine oral and
    craniofacial health, diseases, and conditions in disadvantaged and
    underserved populations. Funds go to a wide variety of different
    scientific approaches designed to reduce and eventually eliminate oral
    and craniofacial diseases and conditions in disadvantaged and
    underserved populations. The program supports both qualitative and
    quantitative approaches.
        The NIDCR will support interventional research that will have a
    meaningful impact on caries, oral and pharyngeal cancer, and
    periodontal disease, and that will influence clinical practice, health
    policy, community and individual action, ultimately eliminating
    disparities in vulnerable people. NIDCR will also fund health
    disparities interventional research beyond that conducted through the
    Centers for Research to Reduce Disparities in Oral Health program.
                              salivary diagnostics
        For many oral and systemic diseases, early detection offers the
    best hope for successful treatment. Oral and systemic diseases can be
    difficult to diagnose, involving complex clinical evaluation and/or
    blood and urine tests that are labor-intensive, expensive, and
    invasive. Now, after many years of research, saliva is poised to be
    used as a noninvasive diagnostic fluid for a number of oral and
    systemic conditions. Saliva, a protective fluid of the oral cavity,
    combats bacteria and viruses that enter the mouth and serves as a first
    line of defense in oral and systemic diseases. It contains many
    compounds indicating a person's overall health and disease status, and,
    like blood or urine, its composition may be affected by a disease--
    therefore, saliva is a mirror of the body. Since saliva is easy to
    collect, it is a good alternative to using blood or urine for
    diagnostic tests.
        The year 2008 was exciting in the incremental development of
    salivary diagnostics. A consortium of NIDCR-supported scientists
    completed the first catalogue of the human salivary proteome, or the
    full set of 1,166 proteins present in saliva. This will help facilitate
    the future testing of saliva as a standard body fluid to detect early
    signs of disease. A team of NIDCR grantees also assembled the first
    panel of salivary protein biomarkers to detect oral squamous cell
    carcinoma (OSCC). This is the most common form of the oral cancers.
        Salivary diagnostic techniques have already been developed for and
    are being used to detect HIV. Saliva could be used as a potential
    monitor of disease progression in systemic disorders, including
    Alzheimer's disease, cystic fibrosis, and diabetes. Specific protein
    markers in human saliva are being investigated that can be identified
    and quantified to provide an early, noninvasive diagnosis for even
    cancers distant from the oral cavity, such as pancreatic and breast
    cancer. Getting a diagnosis used to entail making a trip to the
    doctor's office. The doctor's examination often required the patient
    providing a blood and/or urine sample. Even though getting a diagnosis
    still requires a trip to the doctor's office, scientists are now
    identifying the genes and proteins that are expressed in the salivary
    glands that will help define the patterns and certain conditions under
    which these genes and proteins are expressed in the salivary glands.
    Building on this research, saliva will become a more commonly used
    diagnostic fluid.
                                  oral cancer
        Oral cancer affects 38,000 Americans each year and 350,000 people
    worldwide. The death rate associated with this cancer is especially
    high, due to delayed diagnosis. Oral cancer is any cancerous tissue
    growth located in the mouth. About two-thirds of oral cancers occur in
    the mouth, and about one-third are found in the pharynx. On average,
    only 60 percent of people with the disease will survive more than 5
    years. However, here again, disparities play a role, and only 35
    percent of black men will survive 5 years. Oral cancer occurs most in
    people over the age of 40 and affects more than twice as many men as
    women. Researchers are developing a Point of Care diagnostic system
    (real-time) for rapid on-site detection of saliva-based tumor markers.
    Early detection of oral cancer will increase survival rates, improve
    the quality of life of cancer patients, and result in a significant
    reduction in healthcare costs.
        Oral cancer forms in tissues of the lip or mouth. In 2008,
    approximately 22,900 new cases of oral cancer occurred in the United
    States. Oral cancer claimed roughly 5,390 deaths that year. It
    represents approximately 3 percent of all cancers. This, however,
    translates to 30,000 new cases every year in the United States. More
    than 34,000 Americans will be diagnosed with oral or pharyngeal cancer
    this year. It will cause more than 8,000 deaths, killing roughly 1
    person per hour, 24 hours per day. Of those 34,000 newly diagnosed
    individuals, only half will be alive in 5 years. The death rate for
    oral cancer is higher than that of cancers such as cervical cancer,
    laryngeal cancer, thyroid cancer, or skin cancer. Worldwide, the
    problem is much greater, with more than 400,000 new cases being found
    each year.
        Survival rates can be calculated by different methods for different
    purposes. If oral cancer is caught when the disease has not spread
    beyond the original tumor site, the 5-year relative survival rate is 82
    percent. However, half of oral cancers are not diagnosed until the
    cancer has spread to nearby tissues. At this stage, the 5-year relative
    survival rate drops to 53 percent. Those diagnosed when the cancer has
    spread further, to distant organs, have only a 28 percent 5-year
    relative survival rate. It's important to detect oral cancer early,
    when it can be treated more successfully. Typically, the earlier cancer
    is detected and diagnosed, the more successful the treatment, thus
    enhancing the survival rate.
                                   conclusion
        There are many research opportunities with an immediate impact on
    patient care that need to be pursued. A consistent and reliable funding
    stream for NIH overall, and for NIDCR in particular, is essential for
    continued improvement in the oral health of Americans. Oral cancer is
    one of the most expensive cancers to treat--the average cost for
    treating an advanced case is $200,000. Overcoming cancer health
    disparities is one of the best opportunities we have for lessening the
    burden of cancer. But the burden of cancer is too often greater for the
    poor, for ethnic minorities, and for the uninsured than for the general
    population.
        A great amount of promising research is under way, and the
    potential to improve oral health specifically, and overall health in
    general, is significant. Therefore, we are requesting that NIDCR
    receive a fiscal year 2010 appropriation of $442 million, not including
    the ARRA funding, to help sustain and build upon the discoveries and
    employment opportunities that were created using stimulus funding.
    Thank you for the subcommittee's support of NIH programs in the past,
    and we are grateful for this opportunity to present our views.
                                     ______

        Prepared Statement of the American Academy of Family Physicians
        On behalf of the American Academy of Family Physicians (AAFP), I
    commend President Barack Obama for demonstrating a commitment to a
    strong primary care workforce by seeking to increase training under
    title VII, section 747 of the Public Health Services Act in his fiscal
    year 2010 budget. As one of the largest national medical organizations,
    representing family physicians, residents, and medical students, the
    AAFP recommends that the Senate Appropriations Subcommittee on Labor,
    Health and Human Services, and Education, and Related Agencies build on
    that commitment to title VII section 747 in fiscal year 2010 and
    increase funding for other key HHS programs to allow healthcare reform
    to succeed and support better healthcare all.
              health resources and services administration (hrsa)
        HRSA is charged with improving access to healthcare services for
    people who are uninsured, isolated, or medically vulnerable. One of the
    most critical aspects of this mission is ensuring a healthcare
    workforce which is sufficient to meet the needs of patients and
    communities.
                            hrsa--health professions
        For 40 years, the training programs authorized by title VII of the
    Public Health Services Act evolved to meet our Nation's healthcare
    workforce needs. While it is increasingly clear that our Nation has a
    worsening shortage of primary care physicians, many ``studies have
    found a strong, sometimes dose-dependent associations between title VII
    funding and increased production of primary care graduates, and
    physicians who eventually practice in rural areas and federally
    designated physician shortage areas.'' \1\
    ---------------------------------------------------------------------------
        \1\ Robert Graham Center. Specialty and Geographic Distribution of
    Physician Workforce: What Influences Medical Student & Resident
    Choices? 2009 Washington, DC.
    ---------------------------------------------------------------------------
        The sixth report of the HRSA Advisory Committee on Training in
    Primary Care Medicine and Dentistry recommended an annual minimum level
    of $215 million for the title VII section 747 grant program. The
    subcommittee reasoned that:

        Title VII funds are essential to support major primary care
    training programs that train the providers who work with vulnerable
    populations. It is critical that funds not only be restored to 2005
    levels, but that funding be increased, as the need for healthcare of
    the public, including those high-risk groups identified in this report,
    increases. It is critical that funds offset the acknowledged rate of
    inflation. This additional funding is also necessary to prepare current
    and future primary care providers for their critical role in responding
    to healthcare challenges including demographic changes in the
    population, increased prevalence of chronic conditions, decreased
    access to care, and a need for effective first-response strategies in
    instances of acts of terrorism or natural disasters.

        Healthcare reform demands that we must modernize workforce and
    education policies to ensure an adequate number of primary care
    physicians trained to serve in the new healthcare delivery model. The
    patient centered medical home will give patients access to preventive
    care and coordination of the care needed to manage chronic diseases as
    well as appropriate care for acute illness. The medical home practice
    model provides improved efficiency and better health because it serves
    as a principal source of access and care. As a result, duplication of
    tests and procedures and unnecessary emergency department visits and
    hospitalizations can be avoided
        Section 747 of title VII, the Primary Care Medicine and Dentistry
    Cluster, is aimed at increasing the number of primary care physicians
    (family physicians, general internists and pediatricians). Section 747
    offers competitive grants for family medicine training programs in
    medical schools and in residency programs. Section 747 is vital to
    stimulate medical education, residency programs, as well as academic
    and faculty development in primary care to prepare physicians to
    support the patient centered medical home.
        The value of title VII grants extends far beyond the medical
    schools that receive them. The United States lags behind other
    countries in its focus on primary care. However, the evidence shows
    that countries with primary care-based health systems have population
    health outcomes that are better than those of the United States at
    lower costs.\2\ Health Professions Grants are one important tool to
    help refocus the Nation's health system on primary care.
    ---------------------------------------------------------------------------
        \2\  Starfield B, et al. The effects of specialist supply on
    populations' health: assessing the evidence. Health Affairs. 15 March
    2005
    ---------------------------------------------------------------------------
        Although HRSA has not released the spending plan for the American
    Recovery and Reinvestment Act (ARRA) health professions training funds
    for fiscal year 2009-2010, the omnibus appropriation increased section
    747 by less than 1 percent more than the final fiscal year 2008 amount
    to $48,425,000 for fiscal year 2009. It remains well below the $92
    million provided for Primary Care Medicine and Dentistry Training in
    fiscal year 2003. The Nation needs significant additional support from
    section 747 because it is the only national federally funded program
    that provides resources for important innovations necessary to increase
    the number of physicians who will lead the primary care teams providing
    care in patient-centered medical homes.
        AAFP recommends a substantial increase in the fiscal year 2010
    appropriation bill for the Health Professions Training Programs
    authorized under title VII of the Public Health Services Act. We
    respectfully request that the subcommittee provide $215 million for the
    section 747, the Primary Care Medicine and Dentistry Cluster, which
    will signal the commitment of Congress to reform healthcare delivery in
    this Nation.
                   hrsa--national health service corps (nhsc)
        NHSC offers scholarship and loan repayment awards to primary care
    physicians, nurse practitioners, dentists, mental and behavioral health
    professionals, physician assistants, certified nurse-midwives, and
    dental hygienists serving in underserved communities. Research has
    shown that debt plays a complex yet important role in shaping career
    choices for medical students. The NHSC offers financial incentives for
    the recruitment and retention of family physicians to practice in
    underserved communities without adequate access to primary care. The
    AAFP supports the work of the NHSC toward the goal of full funding for
    the training of the health workforce and zero disparities in
    healthcare.
        AAFP respectfully requests that the subcommittee fully fund these
    important scholarship and loan repayment programs by providing the
    authorized amount of $235 million for NHSC in fiscal year 2010.
                               hrsa--rural health
        Americans in rural areas face more barriers to care than those in
    urban and suburban areas. Rural residents also struggle with the higher
    rates of illness associated with lower socioeconomic status.
        Family physicians provide the majority of care for America's
    underserved and rural populations.\3\ Despite efforts to meet
    scarcities in rural areas, the shortage of primary care physicians
    continues. Studies, whether they be based on the demand to hire
    physicians by hospitals and physician groups or based on the number of
    individuals per physician in a rural area, all indicate a need for
    additional physicians in rural areas.
    ---------------------------------------------------------------------------
        \3\  Hing E, Burt CW. Characteristics of office-based physicians
    and their practices: United States, 2003-04. Series 13, No. 164.
    Hyattsville, MD: National Center for Health Statistics. 2007.
    ---------------------------------------------------------------------------
        HRSA's Office of Rural Health administers a number of programs to
    improve healthcare services to the quarter of our population residing
    in rural communities. Rural Health Policy Development and Outreach
    Grants fund innovative programs to provide healthcare in rural areas.
    State rural health offices, funded through the NHSC budget, help States
    implement these programs so that rural residents benefit as much as
    urban patients.
        AAFP encourages the subcommittee to provide adequate funding in the
    fiscal year 2010 appropriation bill for the important programs
    administered by HRSA's Office of Rural Health to address the many
    unique health service needs of rural communities.
               agency for healthcare research and quality (ahrq)
        The mission of AHRQ--to improve the quality, safety, efficiency,
    and effectiveness of health care for all Americans--closely mirrors
    AAFP's own mission. AHRQ is a small agency with a huge responsibility
    for research to support clinical decisionmaking, reduce costs, advance
    patient safety, decrease medical errors, and improve healthcare
    quality, and access. Family physicians recognize that AHRQ has a
    critical role to play in promoting healthcare safety, quality, and
    efficiency initiatives.
                    ahrq--comparative effectivenss research
        One of the hallmarks of the patient centered medical home is
    evidence-based medicine. Comparative effectiveness research, which
    compares the impact of different options for treating a given medical
    condition, is vital to quality care. Studies comparing various
    treatments (e.g., competing drugs) or differing approaches (e.g.,
    surgery and drug therapy) can inform clinical decisions by analyzing
    not only costs but the relative medical benefits and risks for
    particular patient populations.
        AAFP commends the Congress for including $1.1 billion in ARRA for
    comparative effectiveness research which holds out the promise of
    reducing healthcare costs while improving medical outcomes.
        AAFP respectfully suggests that the subcommittee provide at least
    $405 million for AHRQ in the fiscal year 2010 appropriations bill, an
    increase of $32 million above the fiscal year 2009 level.
                                     ______

    Prepared Statement of the American Association for Geriatric Psychiatry
        The American Association for Geriatric Psychiatry (AAGP)
    appreciates this opportunity to comment on issues related to fiscal
    year 2010 appropriations for mental health research and services. AAGP
    is a professional membership organization dedicated to promoting the
    mental health and well being of older Americans and improving the care
    of those with late-life mental disorders. AAGP's membership consists of
    approximately 2,000 geriatric psychiatrists as well as other health
    professionals who focus on the mental health problems faced by aging
    adults. Although we generally agree with others in the mental health
    community about the importance of sustained and adequate Federal
    funding for mental health research and treatment, AAGP brings a unique
    perspective to these issues because of the elderly patient population
    served by our members.
       a national health crisis: demographic projections and the mental
                               disorders of aging
        With the baby boom generation nearing retirement, the number of
    older Americans with mental disorders is certain to increase in the
    future. By the year 2010, there will be approximately 40 million people
    in the United States older than the age of 65. More than 20 percent of
    those people will experience mental health problems.
        The cost of treating mental disorders can be staggering. For
    example, it is estimated that total costs associated with the care of
    patients with Alzheimer's disease is more than $100 billion per year in
    the United States. Psychiatric symptoms (including depression,
    agitation, and psychotic symptoms) affect 30 to 40 percent of people
    with Alzheimer's and are associated with increased hospitalization,
    nursing home placement, and crippling family burden. These psychiatric
    symptoms, associated with Alzheimer's disease, can increase the cost of
    treating these patients by more than 20 percent. However, these costs
    pale when compared to the costs of not treating mental disorders
    including lost work time, co-morbid illness, and increased nursing home
    utilization. It is also important to note the added burden, financial
    and emotional, on family caregivers, as the Nation's informal
    caregiving system is already under tremendous strain and will require
    more support in the years to come.
      preparing a workforce to meet the mental health needs of the aging
                                   population
        In 2008, the Institute of Medicine (IOM) released a study of the
    readiness of the Nation's healthcare workforce to meet the needs of its
    aging population. The Re-tooling for an Aging America: Building the
    Health Care Workforce called for immediate investments in preparing our
    healthcare system to care for older Americans and their families.
    Virtually all healthcare providers need to be fully prepared to manage
    the common medical and mental health problems of old age. In addition,
    the number of geriatric health specialists, including mental health
    providers, needs to be increased both to provide care for those older
    adults with the most complex issues and to train the rest of the
    workforce in the common medical and mental health problems of old age.
    The small numbers of specialists in geriatric mental health, combined
    with increases in life expectancy and the growing population of the
    nation's elderly, foretells a crisis in healthcare that will impact
    older adults and their families nationwide. Unless changes are made
    now, older Americans will face long waits, decreased choice, and
    suboptimal care.
        In order to implement the IOM report, AAGP believes that there are
    several critical issues that this subcommittee should address:
    IOM Study on Geriatric Mental Health Workforce
        AAGP believes that the broad scope of the 2008 IOM study, while
    meeting a crucial need for information on the many issues regarding the
    health workforce for older adults, precluded the in-depth consideration
    of the workforce needed for treating mental illness. The study should
    be followed by a complementary study focused on the specific challenges
    in the geriatric mental health field. This study should follow up the
    general IOM study in two specific ways: it should examine the access
    and workforce barriers unique to geriatric mental healthcare services;
    and, in discussing possible alternative models of geriatric service
    delivery (such as medical homes, PACE programs, collaborative care
    models like those demonstrated in the IMPACT and PROSPECT studies), it
    should articulate the importance of integrating geriatric mental health
    services as intrinsic components. ``The Retooling the Health Care
    Workforce for an Aging America Act,'' S. 245/H.R. 46, contains a
    provision mandating this additional study.
        In discussions with AAGP, the senior staff of IOM suggested the
    following language for inclusion in the Labor, Health and Human
    Services, and Education, and Related Agencies appropriations bill:
        The subcommittee provides $1,000,000 for a study by the Institute
    of Medicine of the National Academy of Sciences to determine the multi-
    disciplinary mental health workforce needed to serve older adults. The
    initiation of this study should be not later than 60 days after the
    date of enactment of this act, whereby the Secretary of Health and
    Human Services shall enter into a contract with the IOM to conduct a
    thorough analysis of the forces that shape the mental healthcare
    workforce for older adults, including education, training, modes of
    practice, and reimbursement.
    Title VII Geriatric Health Professions Education Programs
        The Bureau of Health Professions in the HHS Health Resources and
    Services Administration (HRSA) administers programs aimed to help to
    assure adequate numbers of healthcare practitioners for the Nation's
    geriatric population, especially in underserved areas.
        The geriatric health professions program supports three important
    initiatives. The Geriatric Education Center (GEC) Program, within
    defined geographic areas, provides interdisciplinary training for
    healthcare professionals in assessment, chronic disease syndromes, care
    planning, emergency preparedness, and cultural competence unique to
    older Americans. The Geriatric Training for Physicians, Dentists, and
    Behavioral and Mental Health Professionals (GTPD Program) provides
    fellows with exposure to older adult patients in various levels of
    wellness and functioning and from a range of socioeconomic and racial/
    ethnic backgrounds. The Geriatric Academic Career Awards (GACA) support
    the academic career development of geriatricians in junior faculty
    positions who are committed to teaching geriatrics in medical schools
    across the country. GACA recipients are required to provide training in
    clinical geriatrics, including the training of interdisciplinary teams
    of healthcare professionals. AAGP supports increased funding for these
    programs as a means to increase geriatric specialist healthcare
    providers.
        Specifically, AAGP supports expanding the number of GECs across the
    Nation; expanding GEC grants to offer mini-fellowships in geriatrics to
    faculty members of health professions schools in all disciplines;
    enhancing GACA awards to support and retain clinician educators from a
    variety of disciplines as they advance in their careers; and providing
    full funding for the National Center for Workforce Analysis to analyze
    current and projected needs for healthcare professionals and
    paraprofessionals in the long-term care sector.
     national institutes of health (nih) and national institute of mental
                                 health (nimh)
        With the graying of the population, mental disorders of aging
    represent a growing crisis that will require a greater investment in
    research to understand age-related brain disorders and to develop new
    approaches to prevention and treatment. Even in the years in which
    funding was increased for NIH and the NIMH, these increases did not
    always translate into comparable increases in funding that specifically
    address problems of older adults. For instance, according to figures
    provided by NIMH, NIMH total aging research amounts decreased from
    $106,090,000 in 2002 to $85,164,000 in 2006 (dollars in thousands:
    $106,090 in 2002; $100,055 in 2003; $97,418 in 2004; $91,686 in 2005;
    and $85,164 in 2006).
        The critical disparity between federally funded research on mental
    health and aging and the projected mental health needs of older adults
    is continuing. If the mental health research budget for older adults is
    not substantially increased immediately, progress to reduce mental
    illness among the growing elderly population will be severely
    compromised. While many different types of mental and behavioral
    disorders occur in late life, they are not an inevitable part of the
    aging process, and continued and expanded research holds the promise of
    improving the mental health and quality of life for older Americans.
    This trend must be immediately reversed to ensure that our next
    generation of elders is able to access effective treatment for mental
    illness. Federal funding of research must be broad-based and should
    include basic, translational, clinical, and health services research on
    mental disorders in late life.
        As the NIMH utilizes the new funding from ``The American Recovery
    and Reinvestment Act of 2009,'' it is necessary that a portion of those
    funds be used to invest in the future evidence-based treatments for our
    Nation's elders. Beginning in fiscal year 2010, annual increases of
    funds targeted for geriatric mental health research at NIH should be
    used to: (1) identify the causes of age-related brain and mental
    disorders to prevent mental disorders before they devastate lives; (2)
    speed the search for effective treatments and efficient methods of
    treatment delivery; and (3) improve the quality of life for older
    adults with mental disorders.
    Participation of Older Adults in Clinical Trials
        Federal approval for most new drugs is based on research
    demonstrating safety and efficacy in young and middle-aged adults.
    These studies typically exclude people who are old, who have more than
    one health problem, or who take multiple medications. As the population
    ages, that is the very profile of many people who seek treatment. Thus,
    there is little available scientific information on the safety of drugs
    approved by the Food and Drug Administration (FDA) in substantial
    numbers of older adults who are likely to take those drugs. Pivotal
    regulatory trials never address the special efficacy and safety
    concerns that arise specifically in the care of the nation's mentally
    ill elderly. This is a critical public health obligation of the
    nation's health agencies. Just as the FDA has begun to require
    inclusion of children in appropriate studies, the agency should work
    closely with the geriatric research community, healthcare consumers,
    pharmaceutical manufacturers, and other stakeholders to develop
    innovative, fair mechanisms to encourage the inclusion of older adults
    in clinical trials. Clinical research must also include elders from
    diverse ethnic and cultural groups. In addition, AAGP urges that
    Federal funds be made available each year for support of clinical
    trials involving older adults.
        As little emphasis has been placed on the development of new
    treatments for geriatric mental disorders, AAGP would encourage the NIH
    to promote the development of new medications specifically targeted at
    brain-based mental disorders of the elderly. AAGP urges this
    subcommittee to request a Government Accountability Office (GAO) study
    on spending by NIH on conditions and illnesses related to the mental
    health of older individuals. The NIH has already undertaken, in its
    Blueprint for Neuroscience Research, an endeavor to enhance cooperative
    activities among NIH Institutes and Centers that support research on
    the nervous system. A GAO study of the work being done by these 16
    Institutes in areas that predominately involve older adults could
    provide crucial insights into possible new areas of cooperative
    research, which in turn will lead to advances in prevention and
    treatment for these devastating illnesses.
                    center for mental health services (cmhs)
        It is critical that there be adequate funding for the mental health
    initiatives under the jurisdiction of the CMHS within the Substance
    Abuse and Mental Health Services Administration (SAMHSA). While
    research is of critical importance to a better future, the patients of
    today must also receive appropriate treatment for their mental health
    problems. The final SAMHSA budgets for the last 8 years have included
    $5 million for evidence-based mental health outreach and treatment to
    the elderly. AAGP urges an increase in funding from $5 million to $20
    million for this essential program to disseminate and implement
    evidence-based practices in routine clinical settings across the
    States. Of that $20 million appropriation, AAGP believes that $10
    million should be allocated to a National Evidence-Based Practices
    Program, which will disseminate and implement evidence-based mental
    health practices for older persons in usual care settings in the
    community. This program will provide the foundation for a longer-term
    national effort that will have a direct effect on the well-being and
    mental health of older Americans.
                                   conclusion
        AAGP recommends:
      --An IOM study on the geriatric mental health workforce to examine
            the access and workforce barriers unique to geriatric mental
            healthcare services and, to articulate the importance of
            integrating geriatric mental health services as intrinsic
            components;
      --Increased funding for the geriatric health professions education
            programs under title VII of the Public Health Service Act;
      --A GAO study on spending by NIH on conditions and illnesses related
            to the mental health of older individuals.
      --Increased funding for evidence-based geriatric mental health
            outreach and treatment programs at CMHS.
                                     ______

        Prepared Statement of the American Association of Immunologists
        The American Association of Immunologists (AAI), a not-for-profit
    professional society representing more than 6,000 of the world's
    leading experts on the immune system, appreciates having this
    opportunity to submit testimony regarding fiscal year 2010
    appropriations for the National Institutes of Health (NIH). The vast
    majority of AAI members--research scientists and physicians who work in
    academia, Government, and industry--depend on NIH funding to advance
    their work and the field of immunology.\1\ With approximately 83
    percent of NIH's approximately $29 billion budget awarded to scientists
    throughout the United States and around the world, NIH funding advances
    not only immunological and biomedical research, but also regional and
    national economies.\2\
    ---------------------------------------------------------------------------
        \1\ The majority of AAI members receive grants from the National
    Institute of Allergy and Infectious Diseases or the National Cancer
    Institute; some receive grants from the National Institute on Aging,
    the National Institute of Arthritis and Musculoskeletal and Skin
    Diseases, or other Institutes or Centers.
        \2\ NIH funding supports ``almost 50,000 competitive grants to more
    than 325,000 researchers at over 3,000 universities, medical schools,
    and other research institutions in every state and around the world.''
    NIH Website: http://www.nih.gov/about/NIHoverview.html (April 28, 2009)
    ---------------------------------------------------------------------------
                     the scope and importance of immunology
        From infectious diseases including influenza, HIV/AIDS, malaria,
    smallpox, and the common cold, to chronic diseases like cancer,
    diabetes, rheumatoid arthritis, asthma, and lupus, the immune system
    plays a central role in human and animal health.\3\ Whether protecting
    the body from disease--or causing it (as in the case of autoimmune
    disease or the rejection of transplanted organs) \4\--the immune system
    is critical to maintaining individual human life and pivotal to
    community and global public health.\5\ Prevention, treatments, and
    cures depend on our understanding of a scientific field that is
    relatively new: although the first vaccine was developed in 1798 (to
    protect against smallpox), most of our basic understanding of the
    immune system has developed in the past 30-40 years, making immunology
    ripe for the many new discoveries that are unfolding every day.
    Emerging areas in immunology involve understanding the immune response
    to environmental threats, to pathogens that threaten to become the next
    pandemic, and to manmade and natural infectious organisms that are
    potential agents of bioterrorism (including plague, smallpox, and
    anthrax). For all of these urgent needs, basic research on the immune
    system provides a crucial foundation for the development of
    diagnostics, vaccines, and therapeutics.
    ---------------------------------------------------------------------------
        \3\ Research on the immune system is also of enormous benefit to
    pets and livestock.
        \4\ The immune system works by recognizing and attacking ``foreign
    invaders'' (e.g., bacteria and viruses) inside the body and by
    controlling the growth of tumor cells. A healthy immune system can
    protect its human or animal host from illness or disease either
    entirely--by attacking and destroying the virus, bacterium, or tumor
    cell--or partially, resulting in a less serious illness. It is also
    responsible for the rejection responses observed following
    transplantation of organs or bone marrow. The immune system can
    malfunction, causing the body to attack itself, resulting in an
    ``autoimmune'' disease, such as Type 1 diabetes, multiple sclerosis, or
    rheumatoid arthritis.
        \5\ NIH funds research ``on `neglected infectious diseases' such as
    malaria, tuberculosis, and a host of tropical diseases--diseases that
    are most prevalent in low-income countries, and that are insufficiently
    researched by the drug industry.'' Testimony of Ron Pollack, Executive
    Director, Families USA, before the House Energy and Commerce
    Subcommittee on Health, hearing on ``Treatments for an Ailing Economy:
    Protecting Health Care Coverage and Investing in Biomedical Research,''
    November 13, 2008, page 4.
    ---------------------------------------------------------------------------
                        recent immunological discoveries
        Immunologists are making significant advances in the development of
    treatments and vaccines against pernicious viruses such as influenza
    strains and HIV. Recently, commonalities were identified among the
    viruses causing seasonal flu, avian flu, and the 1918 pandemic flu,
    indicating that some of the antibodies will react against all these
    strains. Such antibodies could be developed for therapeutic use in the
    case of a flu outbreak. In studies on HIV, immunologists have also
    identified a unique small antibody fragment that is able to stop a
    broad range of HIV strains from entering their target cells. This
    offers hope for a therapy against HIV, which mutates too quickly to be
    responsive to most traditional vaccine strategies.
        An explosion of research has followed the major recent discovery of
    the central role of the inflammasome in immunity. Inflammasomes are
    broadly important molecular complexes within cells that sense
    infections, environmental pollutants, and other ``danger'' signals and
    control the activation of the pro-inflammatory, hormone-like molecules
    interleukin-1 and interleukin-18. Although it may help protect against
    infection, inflammasome-induced interleukin-1 has also been found to be
    a key ``offender'' in many inflammatory and autoimmune diseases.
    Inhibitors of these inflammatory molecules have already demonstrated
    significant clinical efficacy in autoimmune diseases, gout, and
    inherited periodic fever syndromes and are being investigated in other
    illnesses given the potential of the inflammasome to be relevant to
    almost any type of disease.
        Immunologists have made important progress against the increasing
    prevalence of childhood peanut allergies by developing a mouse model
    that is being used to study the basis of this allergy. They have also
    identified a possible treatment course that might reverse the resulting
    potentially life-threatening anaphylaxis.
        Immunologists are also focusing research efforts in the area of
    cancer vaccines. Novel delivery strategies, to effectively present
    tumor antigens or portions of the tumors themselves, have allowed the
    redirection of the immune system to attack cancerous cells within the
    body. Other strategies that manipulate molecules (including the
    inhibitory receptor CTLA4) on immune cells have shown remarkable
    clinical promise for melanoma and prostate cancer. In addition, our
    understanding of how tumors evade and suppress immunity is evolving,
    providing new options for therapy, such as altering the function of T-
    regulatory cells, which normally suppress immunity and thereby promote
    tumor growth.
        Immunologists have also made significant progress in understanding
    autoimmune disease by discovering that furin, a catalytic enzyme,
    prevents some forms of systemic autoimmunity. Scientists have found
    that mice lacking this enzyme had overactive effector T cells as well
    as suppressive T cells with impaired activity, a key finding which may
    lead to treatment of autoimmune disease without suppressing basic
    immunity.
                the nih budget: great promise--and grave danger
        AAI is very grateful to this subcommittee and the Congress for
    doubling the NIH budget from fiscal year 1999 to fiscal year 2003 and
    for addressing the extremely serious problem caused by post-doubling
    subinflationary budget increases through passage of both The American
    Recovery and Reinvestment Act of 2009 (ARRA), which provided $10.4
    billion to NIH, and the fiscal year 2009 Appropriations Act, which
    provided a 3.2 percent ($938 million) budget increase more than fiscal
    year 2008. NIH is now in the extraordinary position of being able to
    fund many worthy projects that had been denied funding, to invest in
    modernizing and enhancing the Nation's research infrastructure, and to
    support scientific and administrative jobs that are crucial to the
    scientific enterprise. This infusion of funds, together with the
    exceptional commitment to advancing scientific research articulated by
    President Obama, is also giving our brightest young students the
    confidence and desire to pursue careers in biomedical research, a
    crucial factor in helping research advances today become cures
    tomorrow.
        Passage of ARRA acknowledged the multi-faceted impact of investing
    in biomedical research and the NIH: improving individual and global
    health, and stimulating local and national economic activity and job
    creation. NIH has estimated that each NIH grant supports on average,
    ``6 to 7 in-part or full scientific jobs.'' \6\ Families USA, a not-
    for-profit consumer advocacy organization, has reported that (1) on
    average, each $1 of NIH funding going into a State generates more than
    twice as much in State economic output, and (2) in fiscal year 2007,
    NIH funding created and supported more than 350,000 jobs that generated
    wages in excess of $18 billion, with an average wage of $52,000 (nearly
    25 percent higher than the average U.S. wage).\7\
    ---------------------------------------------------------------------------
        \6\ Testimony of Raynard S. Kington, M.D., Ph.D., Acting Director,
    National Institutes of Health, Witness appearing before the House
    Subcommittee on Labor, Health and Human Services, and Education, and
    Related Agencies Appropriations Subcommittee, March 26, 2009. Dr.
    Kington was citing the NIH report: ``Estimating the Number of Senior/
    Key Personnel Engaged in NIH Supported Research,'' study issued October
    2008.
        \7\ ``In Your Own Backyard: How NIH Funding Helps Your State's
    Economy,'' Families USA, (June 2008). The report cited numerous
    economic benefits of NIH funding, including: (1) The amount of new
    business activity generated ranged from $8.39 billion in California to
    $13 million in Wyoming; (2) In 14 States, NIH funding generated more
    than $1 billion in new business activity; 3) In 10 States, each $1 of
    NIH funding generated at least $2.26 in economic activity; and (4) In 6
    States, more than 20,000 new jobs were created.
    ---------------------------------------------------------------------------
        While AAI--and the entire biomedical research community--is deeply
    grateful for ARRA's tremendous influx of funds and support, some of the
    constraints accompanying the ARRA funding (i.e., that the funds must be
    obligated by the end of fiscal year 2010 and must be used for immediate
    economic impact, including creating jobs) are somewhat inconsistent
    with the longer view and nature of science and the strong need for
    reliable, sustained funding. Although significant advances can be made
    in 2 years, few projects can be completed in that time. As such, AAI
    looks ahead with concern to future years, when advances poised to be
    made may not come to fruition should ARRA funds end without adequate
    regular appropriations to cushion the reduction. AAI's appropriations
    recommendations for fiscal year 2010 (and ultimately for 2011, though
    not offered here), are premised on that concern and designed to address
    that future.
        aai recommends a 7 percent budget increase for fiscal year 2010
        AAI urges the subcommittee to increase the NIH budget by 7 percent
    in fiscal year 2010. Such an increase would help ensure that research
    and jobs supported by ARRA funds are not lost, and that ongoing
    research would be on track to reach its full potential even after the
    ARRA funding is spent. A 7 percent budget increase would also put NIH
    on the path that most scientists have long sought and urgently need: a
    path of predictable, sustained funding that stabilizes ongoing research
    projects and the overall research enterprise.
        AAI also supports President Obama's request for an additional $1.5
    billion to specifically address recent developments regarding the
    emergent H1N1 (swine) influenza virus. This is an important investment
    in pandemic preparedness, whether that pandemic proves to be influenza
    or a pathogen not yet predicted.
                                other key issues
        Seasonal Influenza and Pandemics.--Seasonal influenza leads to an
    average of more than 200,000 hospitalizations and about 36,000 deaths
    nationwide annually. An influenza pandemic could occur at any time; a
    pandemic as serious as the 1918 pandemic could result in the illness of
    almost 90 million Americans and the death of more than 2 million.\8\
    While researchers and public health professionals must respond to
    emergent threats (such as the current concern related to the H1/N1 flu
    virus), AAI believes that the best preparation for a pandemic is to
    focus on basic research to combat seasonal flu, including building
    capacity, pursuing new production methods (cell based), and seeking
    optimized flu vaccines and delivery methods.
    ---------------------------------------------------------------------------
        \8\ A report issued by Trust for America's Health (``Pandemic Flu
    and the Potential for U.S. Economic Recession'') predicted that a
    severe pandemic flu outbreak could result in the second worst recession
    in the United States since World War II, resulting in a projected cost
    of $683 billion. (March 2007)
    ---------------------------------------------------------------------------
        Bioterrorism.--To best protect against bioterrorism, scientists
    should focus on basic research, including working to understand the
    immune response, identifying new and potentially modified pathogens,
    and developing tools (including new and more potent vaccines) to
    protect against these pathogens.
        The NIH ``Common Fund''.--The NIH Reform Act of 2006 established
    within NIH a ``Common Fund'' (CF) to support trans-NIH initiatives.
    Although AAI recognizes the value of interdisciplinary research, the
    existence of the CF should not permit the funding of lesser quality
    research. Instead, all CF applications should be subject to a
    transparent and rigorous peer-review process like all other funded
    research grant applications. In addition, AAI recommends that the CF
    not grow faster than the overall NIH budget.
        The NIH Public Access Policy (``Policy'').--AAI continues to
    believe that the Policy will duplicate, at great cost to NIH and to
    taxpayers, publications and services which are already provided cost-
    effectively and well by the private sector. Therefore, AAI respectfully
    requests that the subcommittee require that NIH publicly report on the
    cost to date of implementing the Policy (both voluntary and mandatory),
    and projected future costs (including all personnel, administrative,
    infrastructure and enforcement costs) incurred by the various NIH
    Institutes, Centers, and Offices involved.
        Preserving High-quality Peer Review.--NIH's recent completion of
    its ``Peer Review Self-Study'' has resulted in the adoption and
    implementation of numerous changes to its internationally respected and
    highly successful peer review system. While AAI applauds this effort to
    address some legitimate problems with the system, AAI urges that NIH be
    required to conduct timely and transparent evaluation of all pilot
    projects and permanent changes, and provide ample opportunity for
    public comment.
        Ensuring NIH Operations and Oversight.--AAI urges the subcommittee
    to ensure adequate funding for the NIH Research, Management, and
    Services (RM&S) account, which supports the management, monitoring, and
    oversight of all research activities. Particularly with the infusion
    and rapid dissemination of ARRA funds, NIH must be able to properly
    supervise and oversee its increasingly large and complex portfolio.
                                   conclusion
        AAI greatly appreciates this opportunity to submit testimony and
    thanks the Chairman and members of the subcommittee for their strong
    support for biomedical research, the NIH, and the scientists who devote
    their lives to preventing, treating, and curing disease.
                                     ______

      Prepared Statement of the American Association of Nurse Anesthetists

                                     FISCAL YEAR 2010 APPROPRIATIONS REQUEST SUMMARY
                                                 [Dollars in thousands]
    ----------------------------------------------------------------------------------------------------------------
                                                                                              AANA fiscal year 2010
                                           Fiscal year 2009 actual  Fiscal year 2010 budget          request
    ----------------------------------------------------------------------------------------------------------------
    HHS /HRSA /BHPr Title VIII Advanced    Awaiting grant           Grant allocations not    $4,000 for nurse
     Education Nursing, Nurse Anesthetist   allocations--in fiscal   specified.               anesthesia education
     Education Reserve.                     year 2008 awards
                                            amounted to
                                            approximately $3,500.
    Total for Advanced Education Nursing,  $64.44 for Advanced      $64.44 for Advanced      $79.55 for Advanced
     from Title VIII.                       Education Nursing.       Education Nursing.       Education Nursing
    Title VIII HRSA BHPr Nursing           $171,031...............  $263,403...............  $263,403
     Education Programs.
    ----------------------------------------------------------------------------------------------------------------

        The AANA is the professional association for more than 40,000
    Certified Registered Nurse Anesthetists (CRNAs) and student nurse
    anesthetists, representing more than 90 percent of the nurse
    anesthetists in the United States. Today, CRNAs are directly involved
    in delivering 30 million anesthetics given to patients each year in the
    United States. CRNA services include administering the anesthetic,
    monitoring the patient's vital signs, staying with the patient
    throughout the surgery, and providing acute and chronic pain management
    services. CRNAs provide anesthesia for a wide variety of surgical
    cases, and in some States are the sole anesthesia providers in almost
    100 percent of rural hospitals, affording these medical facilities
    obstetrical, surgical, and trauma stabilization, and pain management
    capabilities. CRNAs work in every setting in which anesthesia is
    delivered, including hospital surgical suites and obstetrical delivery
    rooms, ambulatory surgical centers (ASCs), pain management units, and
    the offices of dentists, podiatrists and plastic surgeons.
        Nurse anesthetists are experienced and highly trained anesthesia
    professionals whose record of patient safety in the field of anesthesia
    was bolstered by the Institute of Medicine report in 2000, which found
    that anesthesia is 50 times safer than 20 years previous. (Kohn L,
    Corrigan J, Donaldson M, Ed. To Err is Human. Institute of Medicine,
    National Academy Press, Washington DC, 2000.) Nurse anesthetists
    continue to set for themselves the most rigorous continuing education
    and re-certification requirements in the field of anesthesia. Relative
    anesthesia patient safety outcomes are comparable among nurse
    anesthetists and anesthesiologists, with Pine having concluded, ``the
    type of anesthesia provider does not affect inpatient surgical
    mortality.'' (Pine, Michael MD et al. ``Surgical mortality and type of
    anesthesia provider.'' Journal of American Association of Nurse
    Anesthetists. Vol. 71, No. 2, p. 109-116. April 2003.)
        Even more recently, a study published in Nursing Research indicates
    that obstetrical anesthesia, whether provided by Certified Registered
    Nurse Anesthetists (CRNAs) or anesthesiologists, is extremely safe, and
    there is no difference in safety between hospitals that use only CRNAs
    compared with those that use only anesthesiologists. (Simonson, Daniel
    C et al. ``Anesthesia Staffing and Anesthetic Complications During
    Cesarean Delivery: A Retrospective Analysis.'' Nursing Research, Vol.
    56, No. 1, pp. 9-17. January/February 2007). In addition, a recent AANA
    workforce study showed that CRNAs and anesthesiologists are substitutes
    in the production of surgeries, and it is important to note that
    through continual improvements in research, education, and practice,
    nurse anesthetists are vigilant in their efforts to ensure patient
    safety.
        CRNAs provide the lion's share of anesthesia care required by our
    U.S. Armed Forces through active duty and the reserves. In May 2003 at
    the beginning of ``Operation Iraqi Freedom,'' 364 CRNAs were deployed
    to the Middle East to ensure military medical readiness capabilities.
    For decades, CRNAs have staffed ships, remote U.S. military bases, and
    forward surgical teams without physician anesthesiologist support. In
    addition, CRNAs predominate in rural and medically underserved areas
    and areas where more Medicare patients live. A recent analysis of the
    nurse anesthesia workforce, indicates that in 2006, 38 percent of nurse
    anesthesia graduates went to work in a Medically Underserved Area or
    for a Medically Underserved Population.
          importance of title viii nurse anesthesia education funding
        The nurse anesthesia profession's chief request of the subcommittee
    is for $4 million to be reserved for nurse anesthesia education and
    $79.55 million for advanced education nursing from the title VIII
    program. We feel that this funding request is well justified, as we are
    seeing a vacancy rate of nurse anesthetists in the United States that
    is impacting the public's access to healthcare. The title VIII program,
    which has been strongly supported by members of this subcommittee in
    the past, is an effective means to help address the nurse anesthesia
    workforce demand.
        Increasing funding for advanced education nursing from $64.44
    million to $79.55 million is necessary to meet the continuing demand
    for nursing faculty and other advanced education nursing services
    throughout the United States. The program provides for competitive
    grants that help enhance advanced nursing education and practice and
    traineeships for individuals in advanced nursing education programs.
    This funding is critical to meet the nursing workforce needs of
    Americans who require healthcare. In fact, this funding not only seeks
    to increase the number of providers in rural and underserved America
    but also prepares providers at the master's and doctoral levels,
    increasing the number of clinicians who are eligible to serve as
    faculty.
        The CRNA workforce is seeing a shortage in the clinical and
    educational setting. In 2007, an AANA nurse anesthesia workforce study
    found a 12.6 percent vacancy rate in hospitals for CRNAs, and a 12.5
    percent faculty vacancy rate. The supply of clinical providers has
    increased in recent years, stimulated by increases in the number of
    CRNAs trained. Between 2000-2008, the number of nurse anesthesia
    educational program graduates doubled, with the Council on
    Certification of Nurse Anesthetists (CCNA) reporting 1,075 graduates in
    2000 and 2,158 graduates in 2008. This growth is expected to continue.
    However, it is important to note that even though the number of
    graduates has doubled in 8 years, the nurse anesthetist vacancy rate
    remained steady at around 12 percent, which is likely due to increased
    demand for anesthesia services as the population ages, growth in the
    number of clinical sites requiring anesthesia services, and CRNA
    retirements.
        The problem is not that our 108 accredited programs of nurse
    anesthesia are failing to attract qualified applicants. It is that they
    have to turn them away by the hundreds. The capacity of nurse
    anesthesia educational programs to educate qualified applicants is
    limited by the number of faculty, the number and characteristics of
    clinical practice educational sites, and other factors. A qualified
    applicant to a CRNA program is a bachelor's educated registered nurse
    who has spent at least 1 year serving in an acute care healthcare
    practice environment. Nurse anesthesia educational programs are located
    all across the country, including Alabama, Arkansas, Iowa, Illinois,
    Louisiana, Pennsylvania, Rhode Island, Tennessee, Texas, Washington,
    and Wisconsin.
        Recognizing the important role nurse anesthetists play in providing
    quality healthcare, the AANA has been working with the 108 accredited
    nurse anesthesia educational programs to increase the number of
    qualified graduates. In addition, the AANA has worked with nursing and
    allied health deans to develop new CRNA programs.
        To truly meet the nurse anesthesia workforce challenge, the
    capacity and number of CRNA schools must continue to grow. With the
    help of competitively awarded grants supported by title VIII funding,
    the nurse anesthesia profession is making significant progress,
    expanding both the number of clinical practice sites and the number of
    graduates.
        The AANA is pleased to report that this progress is extremely cost-
    effective from the standpoint of Federal funding. Anesthesia can be
    provided by nurse anesthetists, physician anesthesiologists, or by
    CRNAs and anesthesiologists working together. As mentioned earlier, the
    study by Pine et al confirms, ``the type of anesthesia provider does
    not affect inpatient surgical mortality.'' Yet, for what it costs to
    educate one anesthesiologist, several CRNAs may be educated to provide
    the same service with the same optimum level of safety. Nurse
    anesthesia education represents a significant educational cost-benefit
    for supporting CRNA educational programs with Federal dollars vs.
    supporting other, more costly, models of anesthesia education.
        To further demonstrate the effectiveness of the title VIII
    investment in nurse anesthesia education, the AANA surveyed its CRNA
    program directors in 2003 to gauge the impact of the title VIII
    funding. Of the 11 schools that had reported receiving competitive
    Title VIII Nurse Education and Practice Grants funding from 1998 to
    2003, the programs indicated an average increase of at least 15 CRNAs
    graduated per year. They also reported on average more than doubling
    their number of graduates. Moreover, they reported producing additional
    CRNAs that went to serve in rural or medically underserved areas.
        We believe it is important for the subcommittee to allocate $4
    million for nurse anesthesia education for several reasons. First, as
    this testimony has documented, the funding is cost-effective and
    needed. Second, the title VIII authorization previously providing such
    a reserve expired in September 2002. Third, this particular funding is
    important because nurse anesthesia for rural and medically underserved
    America is not affected by increases in the budget for the National
    Health Service Corps and community health centers, since those
    initiatives are for delivering primary and not surgical healthcare.
    Lastly, this funding meets an overall objective to increase access to
    quality healthcare in medically underserved America.
           title viii funding for strengthening the nursing workforce
        The AANA joins a growing coalition of nursing organizations,
    including the Americans for Nursing Shortage Relief (ANSR) Alliance and
    representatives of the nursing community, and others in support of the
    subcommittee providing a total of $263 million in fiscal year 2010 for
    nursing shortage relief through title VIII. This amount is the same as
    the President's request for 2010. However, AANA asks that of the $263
    million, $79.55 million go to Advanced Education Nursing to help
    increase clinicians in underserved communities and those eligible to
    serve as faculty. The AANA appreciates the support for nurse education
    funding in fiscal year 2009 and past fiscal years from this
    subcommittee and from the Congress.
        In the interest of patients past and present, particularly those in
    rural and medically underserved parts of this country, we ask Congress
    to invest in CRNA and nursing educational funding programs and to
    provide these programs the sustained increases required to help ensure
    Americans get the healthcare that they need and deserve. Quality
    anesthesia care provided by CRNAs saves lives, promotes quality of
    life, and makes fiscal sense. This Federal support for title VIII and
    advanced education nurses will improve patient access to quality
    services and strengthen the Nation's healthcare delivery system.
                            safe injection practices
        Last, as a leader in patient safety, the AANA has been playing a
    vigorous role in the development and projects of the Safe Injection
    Practices Coalition, intended to reduce and eventually eliminate the
    incidence of healthcare facility acquired infections. In the interest
    of promoting safe injection practice, and reducing the incidence of
    healthcare facility acquired infections, we recommend the subcommittee
    provide the following appropriations for fiscal year 2010:
      --Centers for Disease Control and Prevention.--$9 million for
            provider education and patient awareness activities; $8 million
            to promote private-sector healthcare solutions to injection
            safety and infection control problems; $9 million for detection
            and tracking in order to enable States to investigate outbreaks
            of hepatitis and other potential pathogens related to injection
            safety.
      --Agency for Healthcare Research and Quality (AHRQ).--$10 million in
            general patient safety funds for the AHRQ's Ambulatory Patient
            Safety Program.
      --Department of Health and Human Services.--$1 million to expand its
            current focus for reducing HAIs from hospitals to all
            healthcare settings, including outpatient facilities.
                                     ______

          Prepared Statement of the American Academy of Ophthalmology
                               executive summary
        The American Academy of Ophthalmology (AAO) requests a fiscal year
    2010 National Institutes of Health (NIH) funding increase of at least 7
    percent, to a level of $32.4 billion, which represents a modest 3
    percent increase plus the biomedical inflation rate, estimated at 3.8
    percent in fiscal year 2009. This increase is necessary to keep pace
    with inflation and rebuild the base, since NIH has lost 14 percent of
    its purchasing power during the past six funding cycles. AAO commends
    the congressional leadership's actions in fiscal year 2008 and 2009 to
    increase NIH funding, including the $150 million in the fiscal year
    2008 supplemental dedicated to investigator-initiated grants, the $10.4
    billion in 2-year stimulus NIH funding within the American Recovery and
    Reinvestment Act (ARRA), and the final fiscal year 2009 appropriations
    inflationary increase of 3.2 percent. However, NIH needs sustained and
    predictable funding to rebuild its base and support multi-year,
    investigator-initiated research, which is the cornerstone of the
    biomedical enterprise. Annual increases of at least 7 percent put NIH
    on a pathway to budget-doubling within the next 10 years. Secure and
    consistent funding for biomedical research is integral to the Nation's
    economic and global competitiveness. NIH is a world-leading institution
    that must be adequately funded so that its research can reduce
    healthcare costs, increase productivity, and save and improve the
    quality of lives.
        AAO requests that Congress make vision health a top priority by
    increasing National Eye Institute (NEI) funding by at least 7 percent,
    to a level of $736 million, in this year that NEI celebrates its 40th
    anniversary. Over the past 6 funding cycles, NEI lost 18 percent of its
    purchasing power. Despite funding challenges, NEI has maintained its
    impressive record of breakthroughs in basic and clinical research that
    have resulted in treatments and therapies to save and restore vision
    and prevent eye disease. NEI will be challenged further, as 2010 begins
    the decade in which more than half of the 78 million Baby Boomers will
    turn 65 and be at greatest risk for aging eye disease. Adequately
    funding the NEI is a cost-effective investment in our Nation's health,
    as it can delay, save, and prevent expenditures, especially to the
    Medicare and Medicaid programs.
        Fiscal year 2010 funding at $736 million enables NEI to expand its
    impressive record of basic and clinical collaborative research that has
    resulted in treatments and therapies to save and restore vision.
        NEI continues to be a leader in basic research--especially that
    which elucidates the genetic basis of ocular disease--and in
    translational research, as those gene discoveries can lead to
    development of diagnostics and treatments. NEI Director Paul Sieving,
    M.D., Ph.D., has reported that one-quarter of all genes identified to
    date through NEI's collaboration with the National Human Genome
    Research Institute (NHGRI) are associated with eye disease/visual
    impairment. Recent examples include:
      --In 2005, NEI reported that gene variants of Complement Factor H
            (CFH), the protein product of which is engaged in the control
            of the body's immune response, are associated with increased
            risk of developing age-related macular degeneration (AMD), the
            leading cause of vision loss. NEI-funded researchers are now
            working on potential therapies, including the manufacture and
            use of a protective version of the CFH protein in an
            augmentation strategy similar to that of treating diabetes with
            insulin. This therapy is under development and expected to
            enter Phase I clinical safety trials in summer 2009.
      --In March 2008, NEI-funded researchers announced that damage from
            both AMD and diabetic retinopathy was prevented and even
            reversed when the protein Robo4 was activated in mouse models
            that simulate the two diseases. Robo4 treated and prevented the
            diseases by inhibiting abnormal blood vessel growth and by
            stabilizing blood vessels to prevent leakage. Since this
            research into the ``Robo4 Pathway'' used animal models
            associated with these diseases that are already used in drug
            development, the time required to test this approach in humans
            could be shortened, expediting approvals for new therapies
      --In late April 2008, researchers funded by the NEI and private
            funding organization Foundation Fighting Blindness reported on
            their use of gene therapy to restore vision in young adults who
            were virtually blind from a severe form of the
            neurodegenerative disease Retinitis Pigmentosa, known as Leber
            Congenital Amaurosis (LCA). Seven years earlier, the
            researchers shared on Capitol Hill results of a preclinical
            study of the same gene therapy, which at the time was
            successfully giving vision to dogs born blind with LCA. The
            subsequent human gene therapy trial validated the process of
            putting genes in the body to restore vision. Although the
            primary goal of the Phase I study was to ensure patient safety,
            the researchers reported through both objective and subjective
            testing that the patients were able to read several additional
            lines on an eye chart, had better peripheral vision, and better
            eyesight in dimly lit settings. In further research, the
            investigators will treat LCA patients as young as 8 years old,
            since they believe the most dramatic results will be seen in
            young children.
      --In late 2008, NEI initiated its new NEI Glaucoma Human genetics
            collaBORation, known as NEIGHBOR, through which seven U.S.
            research teams will lead genetic studies of the disease.
            Glaucoma is called the ``stealth robber of vision'' as it often
            has no symptoms until vision is lost, and anywhere from 50-75
            percent of individuals with it are undiagnosed. It is also the
            leading cause of preventable vision loss in African American
            and Hispanic populations, which emphasizes the vital nature of
            determining the genetic basis of this disease.
        Fiscal year 2010 funding at $736 million enables NEI to fully fund
    new initiatives that more fully characterize eye disease.
        NEI has been a leader in collaborative research, the use of
    networks to study diagnostics and treatments and their use in clinical
    settings, and in ocular epidemiology to characterize the nature and
    frequency of eye disease in diverse populations to better manage public
    health. In fiscal year 2008, NEI reported on/launched the initial phase
    of three important new programs to characterize eye disease requiring
    adequate future funding.
      --In early 2009, the NEI and the National Aeronautics and Space
            Administration (NASA) reported on the use of a compact fiber
            optic probe developed for the space program that has proven
            valuable as the first non-invasive early detection device for
            cataracts, the leading cause of vision loss worldwide. Using a
            laser light technique called dynamic light scattering (DLS),
            which was developed to analyze the growth of protein crystals
            in a zero-gravity environment, the probe measures the amount of
            light scattering by an anti-cataract protein called alpha-
            crystallin. The probe senses protein damage due to oxidative
            stress, a key process involved in many medical conditions
            including age-related cataract and diabetes, as well as
            Alzheimer's and Parkinson's disease.
      --In late 2008, NEI launched a new research network, the Neuro-
            Ophthalmology Research Disease Investigator Consortium, or
            NORDIC. It will initially lead multi-site observational and
            treatment trials, involving nearly 200 community and academic
            practitioners, to address the risks, diagnosis, and treatment
            of two ``rare'' diseases: idiopathic intracranial hypertension
            (visual dysfunction due to increased intracranial pressure) and
            thyroid eye disease (also called Graves' disease, in which
            muscles of the eye enlarge and cause bulging of the eyes,
            retraction of the lids, double vision, decreased vision, and
            irritation). The NEI and NORDIC's Principal Investigator have
            already begun coordinating with the Department of Defense's
            (DOD) newly established Vision Center of Excellence (VCE) about
            the applicability of NORDIC research to combat-related eye
            injuries, especially those associated with Traumatic Brain
            Injury (TBI).
      --There is currently almost no information on the prevalence, risk
            factors, and genetic determinants in Asian Americans--one of
            the fastest growing racial groups in the United States. Studies
            from East Asia have suggested that Asians have a spectrum of
            eye diseases different from that of White Americans, African
            Americans, and Hispanics. In late 2008, NEI launched the
            Chinese American Eye Study to characterize the extent of eye
            disease in Chinese Americans, the largest Asian subgroup in the
            United States. Participants 50 years and older will be
            evaluated for blindness, visual impairment, and eye disease.
            These results will add to the expanding body of knowledge about
            vision health disparities already characterized by NEI in the
            African-American and Hispanic populations.
        Vision impairment/eye disease is a major public health problem that
    increases healthcare costs, reduces productivity, and diminishes
    quality of life.
        The NEI estimates that more than 38 million Americans age 40 and
    older experience blindness, low vision, or an age-related eye disease
    such as AMD, glaucoma, diabetic retinopathy, or cataracts. This is
    expected to grow to more than 50 million Americans by year 2020. The
    economic and societal impact of eye disease is increasing not only due
    to the aging population, but to its disproportionate incidence in
    minority populations and as a co-morbid condition of chronic disease,
    such as diabetes.
        Although the NEI estimates that the current annual cost of vision
    impairment and eye disease to the United States is $68 billion, this
    number does not fully quantify the impact of direct healthcare costs,
    lost productivity, reduced independence, diminished quality of life,
    increased depression, and accelerated mortality. The continuum of
    vision loss presents a major public health problem and financial
    challenge to the public and private sectors.
      --In public opinion polls over the past 40 years, Americans have
            consistently identified fear of vision loss as second only to
            fear of cancer. As recently as March 2008, the NEI's Survey of
            Public Knowledge, Attitudes, and Practices Related to Eye
            Health and Disease reported that 71 percent of respondents
            indicated that a loss of their eyesight would rate as a ``10''
            on a scale of 1 to 10, meaning that it would have the greatest
            impact on their day-to-day life.
        In 2009, the NEI will celebrate its 40th anniversary as the NIH
    Institute that leads the Nation's commitment to save and restore
    vision. During the next decade, more than half of the 78 million Baby
    Boomers will celebrate their 65th birthday and be at greatest risk for
    developing aging eye disease. As a result, sustained, adequate Federal
    funding for the NEI is an especially vital investment in the health,
    and vision health, of our Nation as the treatments and therapies
    emerging from research can preserve and restore vision. Adequately
    funding the NEI can also delay, save, and prevent health expenditures,
    especially those associated with the Medicare and Medicaid programs,
    and is, therefore, a cost-effective investment.
        AAO urges fiscal year 2010 NIH and NEI funding at $32.4 billion and
    $736 million, respectively, reflecting an at-least 7 percent increase
    more than fiscal year 2009.
                                   about aao
        The American Academy of Ophthalmology is a 501c(6) educational
    membership association. AAO is the largest national membership
    association of eye M.D.s with more than 27,000 members, more than
    17,000 of which are in active practice in the United States. Eye M.D.s
    are ophthalmologists, medical, and osteopathic doctors who provide
    comprehensive eye care, including medical, surgical and optical care.
    More than 90 percent of practicing U.S. eye M.D.s are AAO members.
                                     ______

       Prepared Statement of the American Academy of Physician Assistants
        On behalf of the more than 75,000 clinically practicing physician
    assistants in the United States, the American Academy of Physician
    Assistants is pleased to submit comments on fiscal year 2010
    appropriations for Physician Assistant (PA) educational programs that
    are authorized through title VII of the Public Health Service Act.
        A member of the Health Professions and Nursing Education Coalition
    (HPNEC), the Academy supports the HPNEC recommendation to provide at
    least $300 million for title VII programs in fiscal year 2010,
    including a minimum of $7 million to support PA educational programs.
    This would fund the programs at the 2005 funding level, not accounting
    for inflation.
        AAPA recommends that Congress provide additional support to grow
    the PA primary care workforce through healthcare reform initiatives. A
    reformed healthcare system will require a much-expanded primary
    healthcare workforce, both in the private and public healthcare
    markets. For example, the National Association of Community Health
    Centers' March 2009 report, Primary Care Access: An Essential Building
    Block of Health Reform, predicts that in order to reach 30 million
    patients by 2015, health centers will need at least an additional
    15,585 primary care providers, just more than one-third of whom are
    nonphysician primary care professionals.
        The Academy believes that the recommended restoration in funding
    for title VII health professions programs is well justified.
        A review of PA graduates from 1990-2006 demonstrates that PAs who
    have graduated from PA educational programs supported by title VII are
    59 percent more likely to be from underrepresented minority populations
    and 46 percent more likely to work in a rural health clinic than
    graduates of programs that were not supported by title VII.
        A study by the UCSF Center for California Health Workforce Studies
    found a strong association between physician assistants exposed to
    title VII during their PA educational preparation and those who ever
    reported working in a federally qualified health center or other
    community health center.
        Title VII safety net programs are essential to the development and
    training of primary healthcare professionals and, in turn, provide
    increased access to care by promoting healthcare delivery in medically
    underserved communities. Title VII funding is especially important for
    PA programs as it is the only Federal funding available on a
    competitive application basis to these programs.
        The AAPA is very appreciative of the recent funding increases, for
    the title VII Health Professions Programs, in the fiscal year 2009
    omnibus appropriations bill (Public Law 111-8), which appropriated
    $221.7 million, a 14.3 percent increase, more than fiscal year 2008 and
    the American Recovery and Reinvestment Act (Public Law 111-5), which
    invested $200 million in expanding title VII Health Professions
    Programs. However, the AAPA believes that these recent investments only
    begin to rectify the chronic underfunding of these programs and address
    existing and looming shortages of health professionals, especially
    physician assistants. According to HRSA, an additional 30,000 health
    practitioners are needed to alleviate existing health professional
    shortages.
        We wish to thank the members of this subcommittee for your
    historical role in supporting funding for the health professions
    programs, and we hope that we can count on your support to restore
    funding to these important programs in fiscal year 2010 to the fiscal
    year 2005 funding level.
                   overview of physician assistant education
        Physician assistant programs train students to practice medicine
    with physician supervision. PA programs are located within schools of
    medicine or health sciences, universities, teaching hospitals, and the
    Armed Services. All PA educational programs are accredited by the
    Accreditation Review Commission on Education for the Physician
    Assistant.
        The typical PA program consists of 26 months of instruction, and
    the typical student has a bachelor's degree and about 4 years of prior
    healthcare experience. The first phase of the program consists of
    intensive classroom and laboratory study. More than 400 hours in
    classroom and laboratory instruction are devoted to the basic sciences,
    with more than 75 hours in pharmacology, approximately 175 hours in
    behavioral sciences, and almost 580 hours of clinical medicine.
        The second year of PA education consists of clinical rotations. On
    average, students devote more than 2,000 hours, or 50-55 weeks, to
    clinical education, divided between primary care medicine--family
    medicine, internal medicine, pediatrics, and obstetrics and
    gynecology--and various specialties, including surgery and surgical
    specialties, internal medicine subspecialties, emergency medicine, and
    psychiatry. During clinical rotations, PA students work directly under
    the supervision of physician preceptors, participating in the full
    range of patient care activities, including patient assessment and
    diagnosis, development of treatment plans, patient education, and
    counseling.
        After graduation from an accredited PA program, physician
    assistants must pass a national certifying examination developed by the
    National Commission on Certification of Physician Assistants. To
    maintain certification, PAs must log 100 continuing medical education
    hours every 2 years, and they must take a recertification exam every 6
    years.
                          physician assistant practice
        Physician assistants are licensed healthcare professionals educated
    to practice medicine as delegated by and with the supervision of a
    physician. In all States, physicians may delegate to PAs those medical
    duties that are allowed by law and are within the physician's scope of
    practice and the PA's training and experience. All States, the District
    of Columbia, and Guam authorize physicians to delegate prescriptive
    privileges to the PAs they supervise. Nineteen percent of all PAs
    practice in nonmetropolitan areas where they may be the only full-time
    providers of care (State laws stipulate the conditions for remote
    supervision by a physician). Approximately 41 percent of PAs work in
    urban and inner city areas. Approximately 40 percent of PAs are in
    primary care. Roughly 80 percent of PAs practice in outpatient
    settings.
        AAPA estimates that in 2008, more than 257 million patient visits
    were made to PAs and approximately 332 million medications were written
    by PAs.
         critical role of title vii public health service act programs
        Title VII programs promote access to healthcare in rural and urban
    underserved communities by supporting educational programs that train
    health professionals in fields experiencing shortages, improve the
    geographic distribution of health professionals, increase access to
    care in underserved communities, and increase minority representation
    in the healthcare workforce.
        Title VII programs are the only Federal educational programs that
    are designed to address the supply and distribution imbalances in the
    health professions. Since the establishment of Medicare, the costs of
    physician residencies, nurse training, and some allied health
    professions training have been paid through Graduate Medical Education
    (GME) funding. However, GME has never been available to support PA
    education. More importantly, GME was not intended to generate a supply
    of providers who are willing to work in the Nation's medically
    underserved communities--the purpose of title VII.
        Furthermore, title VII programs seek to recruit students who are
    from underserved minority and disadvantaged populations, which is a
    critical step towards reducing persistent health disparities among
    certain racial and ethnic U.S. populations. Studies have found that
    health professionals from disadvantaged regions of the country are 3 to
    5 times more likely to return to underserved areas to provide care.
        It is also important to note that a December 2008 Institute of
    Medicine report characterized HRSA's health professions programs as
    ``an undervalued asset.''
                  title vii support of pa educational programs
        Targeted Federal support for PA educational programs is authorized
    through section 747 of the Public Health Service Act. The program was
    reauthorized in the 105th Congress through the Health Professions
    Education Partnerships Act of 1998, Public Law 105-392, which
    streamlined and consolidated the Federal health professions education
    programs. Support for PA education is now considered within the broader
    context of training in primary care medicine and dentistry.
        Public Law 105-392 reauthorized awards and grants to schools of
    medicine and osteopathic medicine, as well as colleges and
    universities, to plan, develop, and operate accredited programs for the
    education of physician assistants, with priority given to training
    individuals from disadvantaged communities. The funds ensure that PA
    students from all backgrounds have continued access to an affordable
    education and encourage PAs, upon graduation, to practice in
    underserved communities. These goals are accomplished by funding PA
    educational programs that have a demonstrated track record of: (1)
    placing PA students in health professional shortage areas; (2) exposing
    PA students to medically underserved communities during the clinical
    rotation portion of their training; and (3) recruiting and retaining
    students who are indigenous to communities with unmet healthcare needs.
        The PA programs' success in recruiting and retaining
    underrepresented minority and disadvantaged students is linked to their
    ability to creatively use title VII funds to enhance existing
    educational programs. For example, PA programs in Texas use title VII
    funds to create new clinical rotation sites in rural and underserved
    areas, including new sites in border communities, and to establish
    nonclinical rural rotations to help students understand the challenges
    faced by rural communities. One Texas program uses title VII funds for
    the development of Web based and distant learning technology and
    methodologies so students can remain at clinical practice sites. In New
    York, a PA program with a 90 percent ethnic minority student population
    uses title VII funding to focus on primary care training for
    underserved urban populations by linking with community health centers,
    which expands the pool of qualified minority role models that engage in
    clinical teaching, mentoring, and preceptorship for PA students.
    Several other PA programs have been able to use title VII grants to
    leverage additional resources to assist students with the added costs
    of housing and travel that occur during relocation to rural areas for
    clinical training.
        Without title VII funding, many of these special PA training
    initiatives would not be possible. Institutional budgets and student
    tuition fees simply do not provide sufficient funding to meet the needs
    of medically underserved areas or disadvantaged students. The need is
    very real, and title VII is critical in meeting that need.
        need for increased title vii support for pa educational programs
        Increased title VII support for educating PAs to practice in
    underserved communities is particularly important given the market
    demand for physician assistants. Without title VII funding to expose
    students to underserved sites during their training, PA students are
    far more likely to practice in the communities where they were raised
    or attended school. Title VII funding is a critical link in addressing
    the natural geographic maldistribution of healthcare providers by
    exposing students to underserved sites during their training, where
    they frequently choose to practice following graduation. Currently, 36
    percent of PAs met their first clinical employer through their clinical
    rotations.
        Changes in the healthcare marketplace reflect a growing reliance on
    PAs as part of the healthcare team. Currently, the supply of physician
    assistants is inadequate to meet the needs of society, and the demand
    for PAs is expected to increase. A 2006 article in the Journal of the
    American Medical Association (JAMA) concluded that the Federal
    Government should augment the use of physician assistants as physician
    substitutes, particularly in urban CHCs where the proportional use of
    physicians is higher. The article suggested that this could be
    accomplished by adequately funding title VII programs. Additionally,
    the Bureau of Labor Statistics projects that the number of available PA
    jobs will increase 49 percent between 2004 and 2014. Title VII funding
    has provided a crucial pipeline of trained PAs to underserved areas.
    One way to assure an adequate supply of physician assistants practicing
    in underserved areas is to continue offering financial incentives to PA
    programs that emphasize recruitment and placement of PAs interested in
    primary care in medically underserved communities.
        Despite the increased demand for PAs, funding has not
    proportionately increased for title VII programs that educate and place
    physician assistants in underserved communities. Nor has title VII
    support for PA education kept pace with increases in the cost of
    educating PAs. A review of PA program budgets from 1984 through 2004
    indicates an average annual increase of 7 percent, a total increase of
    256 percent over the past 20 years, as Federal support has decreased.
                  recommendations on fiscal year 2010 funding
        The American Academy of Physician Assistants urges members of the
    Appropriations Committee to consider the inter-dependency of all public
    health agencies and programs when determining funding for fiscal year
    2010. For instance, while it is critical, now more than ever, to fund
    clinical research at the National Institutes of Health (NIH) and to
    have an infrastructure at the Centers for Disease Control and
    Prevention (CDC) that ensures a prompt response to an infectious
    disease outbreak or bioterrorist attack, the good work of both of these
    agencies will go unrealized if the Health Resources and Services
    Administration (HRSA) is inadequately funded. HRSA administers the
    ``people'' programs, such as title VII, that bring the results of
    cutting edge research at NIH to patients through providers such as PAs
    who have been educated in title VII-funded programs. Likewise, CDC is
    heavily dependent upon an adequate supply of healthcare providers to be
    sure that disease outbreaks are reported, tracked, and contained.
        The Academy respectfully requests that title VII health professions
    programs receive $300 million in funding for fiscal year 2010,
    including a minimum of $7 million to support PA educational programs.
    Thank you for the opportunity to present the American Academy of
    Physician Assistants' views on fiscal year 2010 appropriations.
                                     ______

             Prepared Statement of the Alliance for Aging Research
        Chairman Harkin and members of the subcommittee, for more than two
    decades the not-for-profit Alliance for Aging Research has advocated
    for research to improve the experience of aging for all Americans. Our
    efforts have included supporting Federal funding of aging research by
    the National Institutes of Health (NIH), through the National Institute
    on Aging (NIA) and other Institutes and Centers that work with the NIA
    on cross-cutting initiatives. To this end, the Alliance appreciates the
    opportunity to submit testimony highlighting the important role that
    the NIH plays in facilitating aging research activities and the ever
    more urgent need for increased appropriations to advance scientific
    discoveries to keep individuals healthier longer.
        Many challenges will arise as Americans age in increasing numbers.
    There are approximately 36 million Americans aged 65 and older. That
    group is expected to double in size within the next 20 years, at which
    time at least 20 percent of the U.S. population will be older than 65.
    Of particular concern is the dramatic growth that is anticipated among
    those aged 85 and older. By 2050, 19.4 million Americans will be older
    than the age of 85.
        Late-in-life diseases such as type 2 diabetes, cancer, neurological
    diseases, heart disease, and osteoporosis are increasingly driving the
    need for healthcare services in this country. If rapid discoveries are
    not made now to reduce the prevalence of age-related diseases and
    conditions like these, the costs associated with caring for the oldest
    and sickest Americans will place an unmanageable burden on patients,
    their families, and our healthcare system. The Alliance strongly
    believes that with a relatively modest investment, further advances in
    the area of longevity science could yield tremendous health and
    economic benefits by shortening the period during which humans suffer
    from costly, debilitating diseases.
        Within the NIH, the NIA leads research efforts to better understand
    the nature of aging and to maintain the health and independence of
    Americans as they grow older. The NIA supports a range of genetic,
    biological, clinical, social, and economic research related to aging
    and the diseases of the elderly. Through the Division of Aging Biology,
    the NIA funds research focused on understanding and exploiting the
    mechanisms underlying the aging process. Research supported by the
    Division of Aging Biology program is critically important in that much
    of it is centered around how changes in function considered to be
    ``normal aging'' become risk factors for many age-associated
    infirmities. Other noteworthy NIA-supported projects focus on
    increasing healthspan. These include studies to assess the beneficial
    effects of reducing caloric intake in animals, as well as those to test
    compounds that mimic this process in subjects with the potential to
    extend the years of disease-free life. Both approaches have produced
    promising results that may lead to insights into human applications. By
    capitalizing on these and other successful studies to identify genes
    that influence longevity, investigators hope to delay the onset of
    disease and disability associated with human aging in the future.
        The NIA also participates in multi-Institute collaborations on
    disease-specific research aimed at preventing, diagnosing, and more
    effectively treating age-related illnesses. Action to Control
    Cardiovascular Disease, led by the National, Heart, Lung, and Blood
    Institute in partnership with the NIA and three other NIH Institutes,
    is a large clinical trial of adults with type 2 diabetes who are at
    high risk for cardiovascular disease. The trial involves the aggressive
    testing of interventions to reduce the burden of cardiovascular disease
    in high-risk patients, many of whom are elderly. Major cardiovascular
    disease events result in death for 65 percent of diabetic patients and
    no effective preventative strategies currently exist for this
    vulnerable population. The Alzheimer's Disease Neuroimaging Initiative
    (ADNI) is a major public-private partnership led by the NIA to evaluate
    imaging technologies, biological markers, and other tests to improve
    knowledge surrounding the progression of Alzheimer's disease. ADNI has
    produced a wealth of data that is accessible to researchers worldwide.
    It is believed that ADNI findings could lead to shorter and less costly
    trials for Alzheimer's therapies. As many as 5.3 million people have
    Alzheimer's disease and it drains more than $148 billion from the
    Nation's economy each year. Streamlined clinical trials could
    accelerate the development and approval of more effective AD treatments
    to the benefit of those who are yet to be diagnosed. The Diabetes
    Prevention Program, which was an NIH-supported clinical trial involving
    the NIA, continues to reveal information about diabetes onset,
    prevention an outcomes. It was initially intended to examine the
    effects of multiple interventions for adults at risk of type 2
    diabetes. While it succeeded in identifying lifestyle changes that were
    particularly effective in the 60 and older population, it is the
    analysis of the long-term effects of these interventions on diabetes
    onset that could have the most impact on the 57 million adults who are
    at risk for developing the disease.
        In general, the NIH is the primary funder of biomedical research in
    this country. Eighty percent of all the nonprofit medical research in
    the United States is funded by the NIH. But the unfortunate reality is
    that shrinking budgets have impeded progress. In part the scarcity of
    resources has resulted in a decline of the overall success rate for NIH
    research grant applications. At its lowest point only 1 in 4 research
    proposals could be funded by the NIH. The effect of this has been
    reluctance on behalf of new investigators to submit truly ground-
    breaking research proposals for consideration. While we recognize that
    there is enormous competition for congressional appropriations each
    year, a lack of sustained funding for the NIH will have a devastating
    impact on the rate of basic discovery and the development of
    interventions that could have the significant public health benefits
    for our aging population.
        Until recent actions taken by Congress and the President to provide
    a short-term resource infusion through passage of the American
    Reinvestment and Recovery Act, funding for the NIH had been on a
    downward trajectory. In the 6 years through 2008, a series of nominal
    increases and cuts has amounted to flat funding for the NIH, and as a
    result it has lost as much as 17 percent of its purchasing power. Aging
    in particular is a field of research that had been hampered by this
    stagnant funding. To operate in this environment the NIA and other
    Institutes involved in aging-related research have not been able to
    fund increasing numbers of high-quality research grants each year.
        The Alliance for Aging Research applauds Congress and the Obama
    administration's renewed focus on the importance of medical research in
    improving the overall health of the country. In order to demonstrate a
    strong commitment to bolstering science, we would recommend an increase
    in funding for the NIH of at least 7 percent in fiscal year 2010. This
    increase would begin to restore the NIH's ability to pursue new basic,
    translational, and clinical research opportunities. A $32.4 billion
    budget for the NIH in fiscal year 2010 would allow the NIA specifically
    to increase support of new and existing investigator initiated research
    projects and better facilitate the acceleration of discoveries for a
    wide range debilitating age-related diseases and conditions among our
    growing population of older Americans.
        Mr. Chairman, the Alliance for Aging Research thanks you for the
    opportunity to outline the challenges posed by the aging population
    that lie ahead as you consider the fiscal year 2010 appropriations for
    the NIH and we would be happy to furnish additional information upon
    request.
                                     ______

        Prepared Statement of the American College of Obstetricians and
                                 Gynecologists
        The American College of Obstetricians and Gynecologists (ACOG),
    representing 53,000 physicians and partners in women's healthcare, is
    pleased to offer this statement to the Senate Committee on
    Appropriations, Subcommittee on Labor, Health and Human Services, and
    Education, and Related Agencies. We thank Chairman Harkin, and the
    entire subcommittee for their leadership to continually address women's
    health research at the National Institutes of Health (NIH). The Nation
    has made important strides to improve women's health over the past
    several years, and ACOG is grateful to this subcommittee for its
    commitment to ensure that vital research continues to eliminate disease
    and to ensure valuable new treatment discoveries are implemented.
        The American Recovery and Reinvestment Act (ARRA) made a sizeable
    down payment on healthcare programs that have been underfunded in
    recent years. The $10.4 billion for the National Institutes of Health
    (NIH) and the commitment to comparative effectiveness research will
    help to foster innovation and convey best practices to physicians.
    While ACOG is thankful for the generous funding from the stimulus
    package, funds for NIH must be used within 2 years, limiting the
    ability of programs to be carried out to their completion.
        An increase in funds through the regular appropriations process
    will help supplement programs supported by the stimulus package beyond
    the 2-year mark. The President's budget provides a modest increase of
    1.4 percent, not enough to sustain the 19,000 grant applications that
    have been submitted in the wake of the stimulus, which will result in
    lower pay lines. Therefore, we urge the subcommittee to support an
    appropriation of at least $32.4 billion for NIH, a $2.1 billion
    increase (7 percent) for fiscal year 2010.
                       women's health research at the nih
        NIH Institutes work collaboratively to conduct women's health
    research. The Eunice Kennedy Shriver National Institute of Child Health
    and Human Development (NICHD) conducts the majority of women's health
    research, and has made critical accomplishments in preterm birth,
    contraceptive research, and infertility. The National Cancer Institute
    (NCI) has made monumental discoveries on gynecologic cancers, and the
    National Institute of Diabetes and Digestive and Kidney Diseases
    (NIDDK) works with the NICHD to discover treatments for urinary
    incontinence. The Office of Research on Women's Health (ORWH) in the
    NIH Office of the Director coordinates women's health research projects
    and manages mentoring programs for new investigators.
        Despite the NIH's critical advancements, reduced funding levels
    have made it difficult for research to continue, largely due to the
    lack of new investigators. The NIH advanced women's health research
    during the congressional doubling between fiscal year 1998 and fiscal
    year 2003, but funding increases have been so low since fiscal year
    2003, the NIH budget is almost the same as it was before the doubling.
      office of the director--office of research on women's health (orwh)
    Coordinating and Promoting Women's Health Research Throughout NIH
        Established in September 1990, the Office of Research on Women's
    Health (ORWH) is a focal point for women's health research at the NIH.
        The Building Interdisciplinary Research Careers in Women's Health
    (BIRCWH) is operated by the ORWH, and the Women's Reproductive Health
    Research (WRHR) Career Development Program at the NICHD. BIRCWH
    programs are expanding women's health research through career
    development, increasing diversity in the field of women's health,
    promoting interdisciplinary research training and developing
    independent researchers with backgrounds in high-priority women's
    health research areas. These programs attract new researchers, but low
    pay lines make it difficult for the NIH to maintain them.
        The ORWH recently launched the NIH Women's Health Fellowships in
    Intramural Women's Health Research. This intramural program is funded
    through the Foundation of the NIH, which was established by Congress to
    maximize the resources at the NIH and support medical research through
    public-private partnerships. The fellowships are supported by donations
    from Battelle and AstraZeneca.
        An ob-gyn resident at Loyola University, Chicago, Illinois, is one
    of the first recipients of the fellowship. She is studying the
    difference in severity and prevalence of fibroids in African American
    and white women. The Women's Health Fellowship helps new investigators
    enhance their research skills, and mentor women to senior positions in
    science.
        ACOG urges Congress to increase funding for the ORWH to help
    prepare the next generation of women's health researchers and to
    maintain a high level of research innovation and excellence, in turn
    reducing the incidence of maternal morbidity and mortality and
    discovering cures for other chronic conditions.
                                     nichd
        ACOG supports a $90.6 million increase (7 percent) in funds more
    than fiscal year 2009 for NICHD at NIH. These funds will assist
    research into the following areas:
    Expanding Maternal Health Research
        The Maternal Fetal Medicine Units (MFMU) Network investigates
    clinical questions in maternal fetal medicine and obstetrics, with a
    focus on preterm birth, and has advanced women's health research by
    making several monumental discoveries including using progesterone
    treatments to reduce preterm birth. The MFMU is working at 14 sites
    across the United States to reduce the risks of preterm birth, cerebral
    palsy, and pre-eclampsia (high blood pressure).
    Reducing the Prevalence of Premature Births
        NICHD is helping our Nation understand how adverse conditions and
    health disparities increase the risks of premature birth in high-risk
    racial groups, and how to reduce these risks. Prematurity rates have
    increased almost 35 percent since 1981, accounting for 12.5 percent of
    all births, yet the causes are unknown in 25 percent of cases. Preterm
    births cost the Nation $26 billion annually, $51,600 for every infant
    born prematurely. Direct healthcare costs to employers for a premature
    baby average $41,610, 15 times higher than the $2,830 for a healthy,
    full-term delivery.
        The 2008 Surgeon General's Conference on the prevention of preterm
    birth brought together experts from the public and private sectors to
    discuss key research findings and to develop an agenda to mitigate the
    problem of prematurity. The conference concluded by calling on the
    surgeon general to make the prevention of preterm birth a national
    public health priority. ACOG supports this effort and urges Congress to
    recognize the importance of new research to identify the causes and
    effective interventions for preterm births.
    Improving Contraceptive Research
        The United States has one of the highest unintended pregnancy rates
    of the industrialized nations. Of the approximately 6 million
    pregnancies each year, an estimated one-half is unintended.
    Contraceptive use saves as much as $19 billion in healthcare costs
    annually. Research has found that oral contraceptives are less
    effective in overweight and obese women, yet the causes are unknown. It
    is critical that Congress continue to invest in contraceptive research,
    ensuring that women have access to safe and effective contraceptives to
    help them time and space their pregnancies. The NICHD's research on
    male and female contraceptives can help reduce the number of unintended
    pregnancies and abortions, and improve women's health.
    National Cancer Institute (NCI)
                Developing Gynecologic Cancer Research, Prevention, and
                        Education
      --Effects of Cervical Procedure on Pregnancy.--At the Washington
            University School of Medicine, St. Louis, Missouri, researchers
            are studying the impact of the Loop Electrosurgical Excision
            Procedure (LEEP), which is a common treatment for abnormal
            cells on the cervix, on subsequent pregnancy. This study may
            determine whether LEEP increases the risk of preterm birth and
            other adverse pregnancy outcomes.
      --Stress and Ovarian Cancer.--At the University of Texas, MD Anderson
            Cancer Center, Houston, Texas, researchers are examining the
            effects of chronic stress on growth and progression of ovarian
            cancer along with underlying mechanisms. Based on these
            results, researchers hope to gain a better understanding of the
            adverse effects of chronic stress and discover new strategies
            for blocking its harmful effects on cancer patients.
      --Pediatric Cancer Survivor Fertility.--There are currently more than
            250,000 childhood cancer survivors in the United States, and
            while cancer therapies improve long-term survival, such
            treatments may impair fertility potential and cause premature
            ovarian failure. Research at the University of Pennsylvania--
            Philadelphia, Philadelphia, will provide preliminary data for
            the establishment of a long-term study of pediatric cancer
            survivors and their pregnancy rates, pregnancy outcomes and the
            occurrence of premature menopause.
    Expanding Ovarian Cancer Research
        Despite the women's health research advancements at the NCI, much
    more needs to be done. According to the NCI, there will be 22,430 new
    cases of ovarian cancer and 15,280 deaths from ovarian cancer in the
    United States in 2007. With more ovarian cancer biomarker research, we
    may reduce ovarian cancer. ACOG urges Congress to pass the Ovarian
    Cancer Biomarker Act, S. 2569/H.R. 3689, which would increase funding
    for research and clinical centers at the NCI for risk stratification,
    early detection, and screening of ovarian cancer.
                    increasing gynecologic cancer education
        Public and provider education on gynecologic cancers is critical to
    early detection. When women and their doctors understand the symptoms
    and risk factors of gynecologic cancers they can find appropriate
    medical help quickly, increasing the potential for earlier detection.
    ACOG urges Congress to fully fund Johanna's Law, Public Law 109-475, at
    $10 million in fiscal year 2009, which would increase provider and
    public education on gynecologic cancers, saving thousands of lives.
                                     niddk
    Exploring Treatments for Urinary Incontinence
        The Urinary Incontinence Treatment Network (UITN) at the NIDDK and
    the NICHD, researches urinary incontinence treatments. The UITN
    clinical trials compare the outcomes of commonly used surgical
    procedures, drug therapies, and behavioral treatments for incontinence.
      --The Trial of Mid-urethral Slings.--Researches the outcomes of
            surgical procedures to treat stress urinary incontinence.
            Although these surgical procedures are approved by the Food and
            Drug Administration, researchers are investigating which are
            more effective.
      --The Stress Incontinence Surgical Treatment Efficacy Trial.--Studies
            the long-term outcomes of commonly performed stress urinary
            incontinence treatment surgeries. The Burch procedure and the
            sling produce have estimated cure rates of 60 percent -90
            percent, and researchers are determining which produces the
            best long-term outcome.
      --The Behavior Enhances Drug Reduction of Incontinence.--Studies
            whether adding behavioral treatment to drug therapy makes it
            possible to discontinue drug treatment, and still maintain a
            reduced number of incontinence accidents.
        ACOG urges Congress to increase funding for critical women's health
    research at the NIDDK.
        Again, we would like to thank the subcommittee for its continued
    support of programs to improve women's health, and urge Congress to
    increase funding for the NIH and its Institutes 7 percent more than
    fiscal year 2009 levels in fiscal year 2010.
                                     ______

            Prepared Statement of the American College of Physicians
        Chairman Harkin and Ranking Member Cochran, thank you for allowing
    the American College of Physicians (ACP) to share our views on the
    Department of Health and Human Services budget for fiscal year 2010.
        ACP represents 126,000 internal medicine physicians, residents, and
    medical students. ACP is also the Nation's largest medical specialty
    society and its second largest physician membership organization.
        Today, ACP is urging the following funding levels:
      --Title VII and title VIII programs, under the Public Health Service
            Act, $550 million;
      --National Health Service Corps (NHSC), $235 million;
      --Agency for Healthcare Research and Quality (AHRQ), $405 million;
            and
      --National Institutes of Health (NIH), at minimum a 7 percent
            increase more than the fiscal year 2009 baseline.
                             primary care workforce
        We are experiencing a primary care shortage in this country, the
    likes of which we have not seen. The expected demand for primary care
    in the United States continues to grow exponentially while the Nation's
    supply of primary care physicians dwindles and interest by U.S. medical
    graduates in primary care specialties steadily declines. The reasons
    behind this decline in primary care physician supply are multi-faceted
    and complex. Key factors include the rapid rise in medical education
    debt, decreased income potential for primary care physicians, failed
    payment policies, and increased burdens associated with the practice of
    primary care.
        A strong primary care infrastructure is an essential part of any
    high-functioning healthcare system. In this country, primary care
    physicians provide 52 percent of all ambulatory care visits, 80 percent
    of patient visits for hypertension, and 69 percent of visits for both
    chronic obstructive pulmonary disease and diabetes, yet they comprise
    only one-third of the U.S. physician workforce. Those numbers are
    compelling, considering the fact that primary care is known to improve
    health outcomes, increase quality, and reduce healthcare costs.
        There are many regions of the country that are currently
    experiencing shortages in primary care physicians. The Institute of
    Medicine reports that it would take 16,261 additional primary care
    physicians to meet the need in currently underserved areas alone. To
    help alleviate the shortage of primary care physicians, we believe
    sufficient funding should be provided for title VII and title VIII
    programs, as well as NHSC.
                       title vii and title viii programs
        The health professions education programs, authorized under titles
    VII and VIII of the Public Health Service Act and administered through
    the Health Resources and Services Administration, support the training
    and education of healthcare providers to enhance the supply, diversity,
    and distribution of the healthcare workforce, filling the gaps in the
    supply of health professionals not met by traditional market forces.
    ACP was pleased that the American Recovery and Reinvestment Act (ARRA,
    Public Law 111-5) provided a down payment of $200 million for title VII
    and title VIII programs.
        NHSC, along with the Health Professions and Nursing Education
    Coalition, is recommending that these programs require at least $550
    million to adequately educate and train a healthcare workforce that
    meets the public's healthcare needs. This amount includes restoration
    of title VII to at least the fiscal year 2005 level (close to $300
    million).
        Lower funding or elimination of title VII programs will have an
    immediate impact on the training and recruitment of health professions
    students and the educational infrastructures developed and supported by
    title VII. It is important to note that these programs are unique in
    that they are the only federal investment in interdisciplinary
    training, which is vitally important as care is often provided in
    interdisciplinary settings. These programs are also designed to enhance
    minority representation in the healthcare workforce, which is essential
    when it comes to providing access to care as minority providers are
    more likely than others to care for underserved populations and help
    reduce the shortages in these specific areas. Moreover, not only does
    this funding support essential training programs, it also facilitates
    the delivery of care to the underserved areas of the country through
    the Area Health Education Centers and Health Education and Training
    Centers.
        As the Nation's healthcare delivery system undergoes rapid and
    dramatic changes, an appropriate supply and distribution of health
    professionals has never been more essential to the public's health. The
    title VII and title VIII programs are critical to help institutions and
    programs respond to these current and emerging challenges and ensure
    that all Americans have access to appropriate and timely health
    services.
                                      nhsc
        In conjunction with other stakeholders, ACP is recommending a
    combined appropriation of $235 million for NHSC. We are pleased the
    ARRA provided an additional $300 million, which will enable 4,200 more
    clinicians to access the scholarship and loan repayment programs.
        The NHSC scholarship and loan repayment programs provide payment
    toward tuition/fees or student loans in exchange for service in an
    underserved area. The programs are available for primary medical, oral,
    dental, and mental and behavioral professionals. Participation in the
    NHSC for 4 years or more greatly increases the likelihood that a
    physician will continue to work in an underserved area after leaving
    the program. Over the years, the number of clinicians in those programs
    has grown from 180 to more than 4,000. In 2000, the NHSC conducted a
    large study of NHSC clinicians who had completed their service
    obligation up to 15 years before and found that 52 percent of those
    clinicians continued to serve the underserved in their practice. The
    programs under NHSC have proven to make an impact in meeting the
    healthcare needs of the underserved, and with more appropriations, they
    can do more.
        The NHSC estimates that nearly 50 million Americans currently live
    in health professions shortage areas (HPSAs)--underserved communities
    which lack adequate access to primary care services--and that 27,000
    primary care professionals are needed to adequately serve the people
    living in HPSAs. Currently, more than 4,000 NHSC clinicians are caring
    for nearly 4 million people. The outstanding need remains unmet.
        Limited funding has reduced new NHSC awards from 1,570 in fiscal
    year 2003 to an estimated 947 in fiscal year 2008, a nearly 40 percent
    decrease. The NHSC scholarship program already receives 7 to 15
    applicants for every award available. The National Advisory Council on
    the NHSC has recommended that Congress double the appropriations for
    the NHSC to more than double its field strength to 10,000 primary care
    clinicians in underserved areas.
                                      ahrq
        AHRQ is the leading public health service agency focused on
    healthcare quality. AHRQ's research provides the evidence-based
    information needed by consumers, providers, health plans, purchasers,
    and policymakers to make informed healthcare decisions.
        ACP is dedicated to ensuring AHRQ's vital role in improving the
    quality of our Nation's health and supports a fiscal year 2010 budget
    allocation of $405 million for AHRQ. This amount will allow AHRQ to
    carry out its congressional mandate to improve healthcare quality and
    reduce costs by identifying which treatments work best and at what
    cost. ACP's request of an additional $32 million more than the fiscal
    year 2009 funding level would be designated for increased research in
    patient safety, health information technology, resources for research
    into the causes of and solutions to raising healthcare costs, chronic
    care management, and strategies to translate research into practice.
        The additional $32 million will allow AHRQ to expand its
    investigator-initiated research program, a critically important element
    of our Nation's healthcare research effort. This funding stream
    provides for many clinical innovations--innovations that improve
    patient outcomes. It will also facilitate the translation of research
    into clinical practice and disease management strategies, and address
    the healthcare needs of vulnerable populations. Investment in AHRQ's
    investigator-initiated research is an investment in America's health.
    Additionally, investment in investigator-initiated research represents
    a cost-effective and efficient use of our Federal health research
    dollars. The relatively modest investment provided to clinical
    investigators in the form of grants often result in advancements with
    positive economic implications far outweighing the original investment.
        ACP was pleased that the ARRA provided AHRQ with $300 million for
    comparative clinical effectiveness research. This funding, along with
    an additional $400 million for the Office of the Director of the NIH
    and $400 million to the Secretary of Health and Human Services, will
    stimulate the development of comparative effectiveness research and
    provide a good foundation for the establishment of the recommended,
    national comparative effectiveness entity. Furthermore, the act
    prohibits the Government from using the research for making any
    coverage or payment decisions or issuing clinical guidelines. The sole
    purpose is to develop this research and disseminate the results to all
    stakeholders.
                                      nih
        Together, the fiscal year 2009 omnibus and the ARRA provided $38.5
    billion to NIH, which will fund more than 16,000 new research grants
    for live-saving research into diseases such as cancer, diabetes, and
    Alzheimer's.
        In his budget, the President envisions doubling our investment in
    basic research. Consistent with his proposal, we respectfully urge the
    subcommittee to increase funding for NIH by at least 7 percent more
    than the fiscal year 2009 baseline.
                                   conclusion
        Mr. Chairman and Ranking Member Cochran, thank you for the
    opportunity to offer testimony on the importance of the Department of
    Health and Human Services budget for fiscal year 2010.
        In conclusion, ACP would like to reiterate ACP's recommended
    funding levels:
      --Title VII and title VIII programs, under the Public Health Service
            Act, $550 million;
      --NHSC, $235 million;
      --AHRQ, $405 million; and
      --NIH, at minimum a 7 percent increase more than the fiscal year 2009
            baseline.
        The United States must invest in these programs in order to achieve
    a high-performance healthcare system. ACP greatly appreciates the
    support of the subcommittee on these issues and looks forward to
    working with Congress as you being to work on the fiscal year 2010
    appropriations process.
                                     ______

       Prepared Statement of the American College of Preventive Medicine
        Each year, 50,000 Americans die violent deaths. Homicide and
    suicide are, respectively, the third and fourth leading causes of death
    for people aged 1-39 years. An average of 80 people take their own
    lives every day.
        Before the National Violent Death Reporting System (NVDRS) was
    created, Federal and State public health and law enforcement officials
    collected valuable information about violent deaths, but lacked the
    ability to combine it into one comprehensive reporting system. Instead,
    data was held in a variety of different systems, and policymakers
    lacked the clear picture necessary to develop effective violence
    prevention policies.
        When it was created in 2002, NVDRS promised to capture data that is
    critical to identifying patterns and developing strategies to save
    lives. With a clearer picture of why violent deaths occurs, law
    enforcement and public health officials can work together more
    effectively to identify those at risk and provide effective preventive
    services.
        Currently, NVDRS funding levels only allow the program to operate
    in the following 17 States: Alaska, California, Colorado, Georgia,
    Kentucky, Maryland, Massachusetts, New Jersey, New Mexico, North
    Carolina, Oklahoma, Oregon, Rhode Island, South Carolina, Utah,
    Virginia, and Wisconsin. Nine additional States, plus the District of
    Columbia were previously approved for participation in the NVDRS, but
    were unable to join due to funding shortfalls: Connecticut, Illinois,
    Maine, Michigan, Minnesota, New York, Ohio, and Texas. Several other
    States have expressed an interest in joining once new funding becomes
    available.
        While NVDRS is beginning to strengthen violence and suicide
    prevention efforts in the 17 participating States, many other States
    have been forced to sit idle until additional funding is allocated.
    With the inclusion of $7.5 million for NVDRS in fiscal year 2010, NVDRS
    will be able to expand to additional States and continue its
    incremental growth toward national implementation.
              nvdrs provides critical data for suicide prevention
        Although it is preventable, more than 30,000 Americans die by
    suicide each year, and another 1.8 million Americans attempt it,
    costing more than $3.8 billion in hospital expenses and $13 billion in
    lost earnings.
        In the United States today, there is no comprehensive national
    system to track suicides. However, because NVDRS includes information
    on all violent deaths--include deaths by suicide--information from the
    system can be used to develop effective suicide prevention plans at the
    community, State, and national level.
        Among the ways NVDRS data is being used to inform suicide
    prevention programs: NVDRS data from 13 States uncovered significant
    racially and ethnically based differences in mental illness diagnoses
    and treatment among those who died by suicide. Specifically, whites
    were more likely to have been diagnosed with depression or bipolar
    disorder, while blacks were more likely than other groups to have been
    diagnosed with schizophrenia. Hispanics were less likely to have been
    diagnosed with a mental illness or to have received treatment at all,
    although the family reports of depression were comparable to other
    racial groups. Additionally, NVDRS data from all 17 States show that
    veterans accounted for 26 percent of males who died by suicide in 2004.
    While veterans also accounted for 26 percent of the male U.S.
    population, this finding points to the importance of veterans' services
    to potentially identify and treat at-risk individuals.
        With such information available for the first time, officials in
    participating States are using NVDRS data in myriad ways. For example,
      --With the sixth-highest rate of elder suicide in the Nation, Oregon
            tailored its NVDRS data to develop an epidemiological profile
            of victims and establish an elder suicide prevention plan.
            NVDRS data indicated that most victims of elder suicide in
            Oregon had been suffering from physical illness, and that 37
            percent had visited a doctor in the 30 days prior to their
            death. As a result of this NVDRS data, the State developed an
            elder suicide prevention plan that calls for better integration
            of primary care and mental health services, so that potential
            suicide victims can be better identified and treated. The plan
            also calls for training primary healthcare providers,
            integrating mental healthcare into primary care, and educating
            family members about the risks of suicide and warning signs of
            depression.
      --NVDRS data found that 1 in 4 of Virginia's suicide victims had
            served in the military. Among male victims older than 65, more
            than 60 percent were veterans. These findings indicate that the
            State's suicide prevention and education efforts must extend to
            veterans' hospitals and service providers.
      --NVDRS data provides State health officials in South Carolina with
            vital information that indicates behavior patterns, enables
            health officials to identify individuals at risk, and to
            intervene early with appropriate preventive measures. After
            NVDRS data showed that more than 40 percent of suicide victims
            were currently or formerly receiving mental health treatment or
            tested positive for psychiatric medication, the State
            established its first ever suicide prevention plan, which also
            included the formation of a Suicide Prevention Task Force.
        nvdrs provides critical data to protect children and adolescents
        Child abuse and other violence involving children and adolescents
    remains a problem in America, and it is only through a comprehensive
    understanding of its root causes that many needless deaths can be
    prevented. Studies suggest that between 3.3 and 10 million children
    witness some form of domestic violence annually. Additionally, 1,387
    children died as a result of abuse or neglect in 2004, according to the
    Federal Administration on Children, Youth, and Families, part of the
    Department of Health and Human Services.
        Children are most vulnerable and most dependent on their caregivers
    during infancy and early childhood. Sadly, NVDRS data has shown that
    young children are at the greatest risk of homicide in their primary
    care environments. Combined NVDRS data from Alaska, Maryland,
    Massachusetts, New Jersey, Oregon, South Carolina, and Virginia
    determined that African American children 4 years old and younger are
    more than four times more likely to be victims of homicide than
    Caucasian children, and that homicides of children 4 and under are most
    often committed by a parent or caregiver in the home. The data also
    shows that household items, or ``weapons of opportunity,'' were most
    commonly used, suggesting that poor stress responses may be factors in
    these deaths. Knowing the demographics and methods of abusers can lead
    to more effective, targeted prevention programs.
        Other examples of how NVDRS data is informing programs to protect
    children and adolescents from violence, include the following:
      --Data from NVDRS pilot sites in Connecticut, Maine, Utah, Wisconsin,
            Pennsylvania, and California found that almost 30 percent of
            suicide victims age 17 and under told someone they felt
            suicidal. Many teen suicides also appear to be linked to recent
            events in their lives, with nearly one-third of suicides taking
            place on the same day as a crisis and almost half within the
            same week. This data underscores the importance of developing
            community-based programs to rapidly respond to the warning
            signs of suicide.
      --With data generated by NVDRS, State health officials in
            Massachusetts have been able to monitor suicides and homicides
            more accurately among specific populations, such as foster
            children and youths in custody. The NVDRS data has been used to
            secure grants for violence prevention programs for these
            special populations, about whom data had previously been
            impossible to obtain.
       nvdrs provides critical data to prevent intimate partner violence
        While intimate partner violence has declined along with other
    trends in crime over the past decade, thousands of Americans still fall
    victim to it every year. Women are much more likely than men to be
    killed by an intimate partner. Intimate partner homicides accounted for
    33.5 percent of the murders of women and less than four percent of the
    murders of men in 2000, according to the Bureau of Justice Statistics.
        Although the program is still in its early stages, NVDRS is
    providing critical information that is helping law enforcement and
    health and human service officials allocate resources and develop
    programs in ways that target those most at risk for intimate partner
    violence, thereby preventing needless deaths. For example, NVDRS data
    shows that while occurrences are rare, most murder-suicide victims are
    current or former intimate partners of the suspect, and a substantial
    number of victims were the suspect's children. In addition, NVDRS
    indicates that women are about seven times more likely than men to be
    killed by a spouse, ex-spouse, lover, or former lover, and the majority
    of these incidents occurred in the women's homes
        Examples of how State officials are using NVDRS data to better
    understand and prevent intimate partner violence include:
      --Based on an analysis of NVDRS data, the Kentucky Injury Prevention
            Research Center concluded that among women killed by an
            intimate partner, only 39 percent had had filed for a
            restraining order or been seen by or reported to Adult
            Protective Services. This finding underscored a perceived need
            in the community to improve outreach linking potential victims
            to local protective services.
      --Working with the State's NVDRS program, the Alaska Department of
            Law and Public Safety found there is a high risk for intimate
            partner violence, both homicide and suicide, when one partner
            is attempting to leave the relationship. Findings such as this
            one are molding the State's strategy for domestic violence
            prevention.
             strengthening and expanding nvdrs in fiscal year 2010
        At an estimated annual cost of $20 million for full implentation,
    NVDRS is a relatively low-cost program that yields high-quality
    results. While State-specific information provides enormous value to
    local public health and law enforcement officials, national data from
    all 50 States, the U.S. territories and the District of Columbia must
    be obtained to complete the picture and establish effective national
    violence prevention policies and programs.
        That is why the National Violence Prevention Network, a coalition
    of national organizations who advocate for health and welfare, violence
    and suicide prevention, and law enforcement, is calling on Congress to
    provide no less than $7.5 million for NVDRS for fiscal year 2010. The
    cost of not implementing the program is much greater: without national
    participation in the program, thousands of American lives remain at
    risk.
                                     ______

       Prepared Statement of the American College of Preventive Medicine
                                 recommendation
        The American College of Preventive Medicine (ACPM) urges the Labor,
    Health and Human Services, and Education, and Related Agencies
    Appropriations Subcommittee to reaffirm its support for training
    preventive medicine physicians and other public health professionals by
    providing $10.1 million in fiscal year 2010 for preventive medicine
    residency training under the public health, dentistry, and preventive
    medicine line item in title VII of the Public Health Service Act. ACPM
    also supports the recommendation of the Health Professions and Nursing
    Education Coalition that $550 million be appropriated in fiscal year
    2010 to support all health professions and nursing education and
    training programs authorized under titles VII and VIII of the Public
    Health Service Act.
                  the need for preventive medicine is growing
        In today's healthcare environment, the tools and expertise provided
    by preventive medicine physicians are integral to the effective
    functioning of our Nation's public health system. These tools and
    skills include the ability to deliver evidence-based clinical
    preventive services, expertise in population-based health sciences, and
    knowledge of the social and behavioral aspects of health and disease.
    These are the tools employed by preventive medicine physicians who
    practice in public health agencies and in other healthcare settings
    where improving the health of populations, enhancing access to quality
    care, and reducing the costs of medical care are paramount. As the body
    of evidence supporting the effectiveness of clinical and population-
    based interventions continues to expand, so does the need for
    specialists trained in preventive medicine.\1\ \2\ \3\
    ---------------------------------------------------------------------------
        \1\ Berrino, F. Role of Prevention: Cost Effectiveness of
    Prevention. Annals of Oncology 2004; 15:iv245-iv248.
        \2\ Eikjemans G, Takala J. Moving Knowledge of Global Burden into
    Preventive Action. American Journal of Industrial Medicine 2005;
    48:395-399.
        \3\ Ortegon M, Redekop W, Niesen L. Cost-Effectiveness of
    Prevention and Treatment of the Diabetic Foot. Diabetes Care 2004;
    27:901-907.
    ---------------------------------------------------------------------------
        Organizations across the spectrum have recognized the growing
    demand for public health and preventive medicine professionals. The
    Institute of Medicine released a report in 2007 calling for an
    expansion of preventive medicine training programs by an ``additional
    400 residents per year''.\15\ The Health Resources and Services
    Administration's (HRSA) Bureau of Health Professions, using data
    extracted from the Department of Labor, reports that the demand for
    public health professionals will grow at twice the rate of all
    occupations between 2000 and 2010.\4\ The Council on Graduate Medical
    Education recommends increased funding for training physicians in
    preventive medicine.\5\ In addition, the Nation's medical schools are
    devoting more time and effort to population health topics.\6\ These are
    just a few of the examples demonstrating the growing demand for
    preventive medicine.
    ---------------------------------------------------------------------------
        \15\ Training Physicians for Public Health Careers. Institute of
    Medicine. National Academies Press, June 2007.
        \4\ Biviano M. Public Health and Preventive Medicine: What the Data
    Shows. Presented at the 9th Annual Preventive Medicine Residency
    Program Directors Workshop, San Antonio, Texas. HRSA. 2002.
        \5\ Glass JK. Physicians in the Public Health Workforce. In Update
    on the Physician Workforce. Council on Graduate Medical Education.
    2000.
        \6\ Sabharwal R. Trends in Medical School Graduates' Perceptions of
    Instruction in Population-Based Medicine. In Analysis in Brief.
    American Association of Medical Colleges. Vol. 2, No. 1. January 2002.
    ---------------------------------------------------------------------------
        In fact, preventive medicine is the only 1 of the 24 medical
    specialties recognized by the American Board of Medical Specialties
    that requires and provides training in both clinical medicine and
    public health. Preventive medicine physicians possess critical
    knowledge in population and community health issues, disease and injury
    prevention, disease surveillance and outbreak investigation, and public
    health research. Preventive medicine physicians are employed in
    hospitals, State and local health departments, Health Maintenance
    Organizations (HMOs), community and migrant health centers, industrial
    sites, occupational health centers, academic centers, private practice,
    the military, and Federal Government agencies.
        The recent focus on emergency preparedness is also driving the
    demand for these skills. Unfortunately, many experts have expressed
    concerns about the preparedness level of our public heath workforce and
    its ability to respond to emergencies. The nonpartisan, not-for-profit
    Trust for America's Health has published annual reports assessing
    America's pubic health emergency response capabilities. The most recent
    report, released in December 2008, found that neither State nor Federal
    Governments are adequately prepared to manage a public health
    emergency. One reason for this is a significant shortfall in funding
    needed to improve the Nation's public health systems.\7\ Furthermore,
    the Centers for Disease Control and Prevention recently affirmed that
    there are significant holes in U.S. hospital emergency planning efforts
    for bioterrorism and mass casualty management.\8\ These include varying
    levels of training among hospital staff for treating exposures to
    chemical, biological or radiological agents; lack of memoranda of
    understanding with supporting local healthcare facilities; and lack of
    preparedness training for explosive incidents.
    ---------------------------------------------------------------------------
        \7\ Hearne S, Chrissie J, Segal L, Stephens T, Earls M. Ready or
    Not? Protecting the Public's Health from Diseases, Disasters, and
    Bioterrorism 2008; Trust for America's Health.
    www.healthyamericans.org.
        \8\ Niska R, Burt C. Bioterrorism and mass casualty preparedness in
    hospitals: United States, 2003. Advance data from vital and health
    statistics; no 364. Hyattsville, MD: National Center for Health
    Statistics. 2005.
    ---------------------------------------------------------------------------
           the supply of preventive medicine specialists is shrinking
        According to HRSA and health workforce experts, there are personnel
    shortages in many public health occupations, including among others,
    preventive medicine physicians, epidemiologists, biostatisticians, and
    environmental health workers.\9\
    ---------------------------------------------------------------------------
        \9\ Health Professions and Nursing Education Coalition.
    Recommendation for Fiscal Year 2007. March 2006.
    ---------------------------------------------------------------------------
        Exacerbating these shortages is a shrinking supply of physicians
    trained in preventive medicine:
      --In 2002, only 6,893 physicians self-designated as specialists in
            preventive medicine in the United States, down from 7,734 in
            1970. The percentage of total U.S. physicians self-designating
            as preventive medicine physicians decreased from 2.3 percent to
            0.8 percent over that time period.\10\
    ---------------------------------------------------------------------------
        \10\ American Medical Association (AMA). Physician Characteristics
    and Distribution in the U.S. 2004, Table 5.2, p. 323.
    ---------------------------------------------------------------------------
      --Between 1999 and 2006, the number of residents enrolled in
            preventive medicine training programs declined nearly 20
            percent.\11\
    ---------------------------------------------------------------------------
        \11\ AMA. Graduate Medical Education Database. Copyright 1994-2005,
    Chicago, IL.
    ---------------------------------------------------------------------------
      --The number of preventive medicine residency programs decreased from
            90 in 1999 to 71 in 2008-2009.\12\
    ---------------------------------------------------------------------------
        \12\ Magee JH. Analysis of Program Data for Preventive Medicine
    Residencies in the United States: Report to the Bureau of Health
    Resources & Services Administration. Washington, DC: American College
    of Preventive Medicine, 1997.
    ---------------------------------------------------------------------------
        ACPM is deeply concerned about the shortage of preventive medicine-
    trained physicians and the ominous trend of even fewer training
    opportunities. The decline in numbers is dramatic considering the
    existing critical shortage of physicians trained to carry out core
    public health activities. This deficiency will lead to major gaps in
    the expertise needed to deliver clinical prevention and community
    public health. The impact on the health of those populations served by
    HRSA may be profound.
                   funding for residency training is eroding
        Physicians training in the specialty of preventive medicine,
    despite being recognized as an underdeveloped national resource and in
    shortage for many years, are the only medical residents whose graduate
    medical education (GME) costs are not supported by Medicare, Medicaid
    or other third-party insurers. Training occurs outside hospital-based
    settings and therefore is not financed by GME payments to hospitals.
    Both training programs and residency graduates are rapidly declining at
    a time of unprecedented national, State, and community need for
    properly trained physicians in public health and disaster preparedness,
    prevention-oriented practices, quality improvement and patient safety.
    Both the Council on Graduate Medical Education and Institute of
    Medicine have called for enhanced training support.
        Currently, residency programs scramble to patch together funding
    packages for their residents. Limited stipend support has made it
    difficult for programs to attract and retain high-quality applicants;
    faculty and tuition support has been almost nonexistent.\12\ Directors
    of residency programs note that they receive many inquiries about and
    applications for training in preventive medicine; however, training
    slots often are not available for those highly qualified physicians who
    are not directly sponsored by an outside agency (such as the Armed
    Services) or who do not have specific interests in areas for which
    limited stipends are available (such as research in cancer prevention).
    ---------------------------------------------------------------------------
        \12\ Magee JH. Analysis of Program Data for Preventive Medicine
    Residencies in the United States: Report to the Bureau of Health
    Resources & Services Administration. Washington, DC: American College
    of Preventive Medicine, 1997.
    ---------------------------------------------------------------------------
        HRSA--as authorized in title VII of the Public Health Service Act--
    is a critical funding source for several preventive medicine residency
    programs. HRSA funding ($1.1 million in fiscal year 2008) currently
    supports only about 20 physicians in 5 preventive medicine training
    programs,\13\ yet it represents the largest Federal funding source for
    public health and general preventive medicine (PH/GPM) programs.
    Funding is in steady decline; in fiscal year 2002 the level was $1.9
    million.
    ---------------------------------------------------------------------------
        \13\ http://bhpr.hrsa.gov/publichealth/preventive/index.htm.
    Preventive Medicine Residency Training Grants.
    ---------------------------------------------------------------------------
        These programs directly support the mission of the HRSA health
    professions programs by facilitating practice in underserved
    communities and promoting training opportunities for underrepresented
    minorities:
      --Forty percent of HRSA-supported preventive medicine graduates
            practice in medically underserved communities, a rate four
            times the average for all health professionals.\4\ These
            physicians are meeting a critical need in these underserved
            communities.
    ---------------------------------------------------------------------------
        \4\ Biviano M. Public Health and Preventive Medicine: What the Data
    Shows. Presented at the 9th Annual Preventive Medicine Residency
    Program Directors Workshop, San Antonio, Texas. HRSA. 2002.
    ---------------------------------------------------------------------------
      --One-third of preventive medicine residents funded through HRSA
            programs are under-represented minorities, which is three times
            the average of minority representation among all health
            professionals.\4\ Increased representation of minorities is
            critical because (1) under-represented minorities tend to
            practice in medically underserved areas at a higher rate than
            nonminority physicians, and (2) a higher proportion of
            minorities contributes to high-quality, culturally competent
            care.
      --Fourteen percent of all preventive medicine residents are under-
            represented minorities, the largest proportion of any medical
            specialty.\16\
    ---------------------------------------------------------------------------
        \16\ Percentage of ACGME Residents/Fellows Who are Black, Native
    American or Native Hawaiian by Speciality. AAMC/AMA National GME
    census, October 2008.
    ---------------------------------------------------------------------------
     the bottom line: a strong, prepared, public health system requires a
                      strong preventive medicine workforce
        The growing threats of a flu pandemic, disasters, and terrorism has
    thrust public health into the forefront of the Nation's consciousness.
    ACPM applauds recent investments in disaster planning, information
    technology, laboratory capacity, and drug and vaccine stockpiles.
    However, any efforts to strengthen the public health infrastructure and
    disaster response capability must include measures to strengthen the
    existing training programs that help produce public health leaders.
        Many of the public health leaders who guide the Nation's public
    health response in the aftermath of the September 11 attacks and the
    recent hurricane disasters were physicians trained in preventive
    medicine. According to William L. Roper, MD, MPH, Dean of the School of
    Public Health, The University of North Carolina at Chapel Hill,
    ``Investing in public health preparedness and response without
    supporting public health and preventive medicine training programs is
    like building a sophisticated fleet of fighter jets without training
    the pilots to fly them.''
                                     ______

      Prepared Statement of the Association for Clinical Research Training
                summary of recommendations for fiscal year 2010
        Works towards fully funding the emerging Clinical and Translational
    Science Awards (CTSA) program by a providing $532 million of support.
    Continued support for the NIH K-awards for the training of research
    scientists. Continued emphasis on the importance of Comparative
    Effectiveness Research (CER).
        Association for Clinical Research Training (ACRT) is committed to
    improving the Nation's health by increasing the amount and quality of
    clinical research through the expansion and improvement of clinical
    research training. This training is funded by both the National
    Institutes of Health (NIH) and the Agency for Healthcare Research and
    Quality (AHRQ).
        The National Alliance of Socieities for Clinical Research Resources
    (NASCRR) is comprised of the national organizations that provide
    leadership in the field of clinical and translational medical research.
    NASCRR coalesces around areas of common concern for the entire
    community and works in support of the mission of the National Center
    for Research Resources (NCRR).
        Let me begin by thanking the subcommittee for showing a strong
    commitment to improving public health through the recently passed
    fiscal year 2009 omnibus appropriations package. The legislation
    included $938 million for NIH; the first meaningful funding increase to
    the agency's baseline budget in many years. ACRT applauds the
    subcommittee for its role in securing this funding, and we hope that
    significant funding increases for NIH and other public health programs
    will continue in subsequent fiscal years.
        Clinical research is an increasingly important component of medical
    research. A large, well-trained workforce is required to ensure that
    breakthroughs in bioscience are translated into improved treatment
    options for patients. Currently, the field of clinical research is
    facing the same work-force shortage and retention issues felt
    throughout the medical research community. Additionally, clinical
    investigators undertake comparative effectiveness research activities
    and as investment in this area is increased, it stands to reason that
    the present pressures on the clinical research community will be
    exacerbated. Commitments to increase funding for clinical research
    training activities and programs must be made to ensure that in the
    future, the workforce is robust and capable of improving the public
    health in an effective and expeditious manner.
               the importance of fully funding the ctsa program.
        The CTSA program is a critical effort to modernize this Nation's
    clinical and translational research infrastructure, and bring the
    entire field of medical research into the 21st century. To accomplish
    this task, the program has identified four important goals; improving
    the way biomedical research is conducted across the country, reducing
    the time it takes for laboratory discoveries to become treatments for
    patients, engaging communities in clinical research efforts, and
    training the next generation of clinical and translational researchers.
        The CTSA program is intended to assist institutions in creating a
    home for clinical and translational science. The program started with
    12 academic health centers located throughout the Nation, and the NIH's
    plan for the CTSAs will ultimately link 60 institutions together to
    energize the discipline of clinical and translational science.
    Currently, there are 38 CTSA sites.
        Recent years of near-level funding for NIH have hampered NCRR's
    budget and drained the pool of resources that could be committed to
    supporting the growing CTSA network.
        NCRR has to reduce the size of awards by about half in some
    instances. NCRR does not have the funds necessary to support 60 sites.
        When applying to be part of the CTSA network, institutions had to
    identify the types of programs and research they would be conducting.
    The proposals that were deemed meritorious were subsequently funded,
    but in most cases at a reduced level.
        While we applaud the funding for NCRR that was provided through the
    economic stimulus package, this additional money has created a
    frustrating situation for CTSA-recipients. Presently, NCRR and other
    NIH Institutes, Centers, and Offices are holding competitions and
    accepting proposals to allocate the stimulus funds. Many of the
    research activities which are being proposed are very similar to
    activities the CTSA's already outlined in their initial peer-reviewed
    applications, but have been unable to undertake due to a lack of
    funding. In fact, many CTSA's are simply peeling off the programs which
    have been approved, but unfunded and redundantly competing for stimulus
    funds. Trying to fully fund CTSA activities in this manner is overly
    complicated and inefficient.
        The CTSA program is currently funded at just under $475 million.
    You will note from the attached professional judgment provided by NCRR
    that to facilitate appropriate implementation, the program requires a
    funding level of $532 million in fiscal year 2010. Additionally, this
    document states that to fully implement the program and support a
    network of 60 centers by 2011, a funding level of $669 million is
    required.
        It is our recommendation that the subcommittee work towards full
    implementation of the CTSA program by providing $532 million in support
    for fiscal year 2010.
          the importance of continuing to support the k-awards program
        As the CTSA program is rolled out, it is meant to subsume the
    activities of other NCRR programs, such as the K-30 Clinical Research
    Curriculum Awards (CRCA). However, while flat budgets slowed
    implementation of the CTSA network, the phasing out of K-30 awards
    continued on unimpeded. Last year the subcommittee showed strong
    leadership and urged NCRR to continue the CRCA program for those
    institutions that had not yet received a CTSA. I am pleased to inform
    you that the NCRR has complied with this request, and recently the
    Center issued the K-30 recompetition notice. Thank you for taking an
    interest in clinical research training and please continue to do so
    moving forward.
        K-30 awards remain an exceedingly cost-effective approach to
    improving the quality of training in clinical research. This efficiency
    is seen throughout the larger K-award program which has many mechanisms
    that go beyond the scope of the K-30's to provide support for career
    development for individual researchers. Highly trained clinical
    researchers are needed in order to capitalize on the many profound
    developments and discoveries in basic science and to translate them to
    clinical settings at all research institutions.
        While the K-30 awards are primarily funded by NCRR, these
    individualized K-awards, like the K-23 Mentored Patient-Oriented
    Research Career Development Awards and the K-24 Midcareer Investigator
    Awards in Patient-Oriented Research are administered by many NIH
    Institutes and Centers. K-23 awards support the career development of
    investigators who have made a commitment to focus their research
    endeavors on patient-oriented research. The purpose of K-24 awards is
    to provide support to mid-career health-professional doctorates that
    are typically at the Associate Professor level for protected time to
    devote to patient-oriented research and to act as research mentors
    primarily for clinical residents, clinical fellows and/or junior
    clinical faculty.
        The universe of K-awards is vast and also includes K-01 Mentored
    Research Scientist Development Awards and K-08 Mentored Clinical
    Scientist Development Awards, amongst others. All of these awards
    mechanism fill a critical research training niche. As the role of the
    clinical investigator gains prominence, it is important to begin
    raising awareness of these mechanisms and to bolstering their support.
        We ask the subcommittee to emphasize its interest in the K-award
    programs and to urge NIH to continue to provide adequate support for K-
    awards moving forward.
                  the importance of continuing to support cer
        The American Recovery and Reinvestment Act of 2009 contained $1.1
    billion for CER activities at NIH and AHRQ. NIH has been conducting
    critical CER for some time and we are pleased that Congress is
    beginning to appreciate the importance of these activities.
        Within the $1.1 billion allocation for CER, $400 million was
    provided to NIH. CTSA program recipients should compete well for a
    portion of these funds as many sites consider CER a crucial component
    of clinical and translational research. Additionally, the CTSA network
    is intended to be a collaborative endeavor capable of leveraging great
    resources to maximize productivity. As CER gains prominence, we hope
    the Subcommittee will recognize the CTSA network as an ideal home for
    comparative effectiveness research activities.
        CER is just one example of how the role of the clinical
    investigator is becoming more critical in a modern healthcare system.
    However, without bolstering clinical research training opportunities we
    will not be able to properly prepare the next generation of clinical
    researchers. This will slow hinder our Nation's capability to stay on
    the cutting edge of medical research and slow the development of new
    treatment options for patients.
        We ask the subcommittee to continue to appreciate and support CER
    activities at NIH and AHRQ. We also ask that concurrently the
    subcommittee express its interest in expanding clinical research
    training opportunities at both NIH and AHRQ.
        Thank you for this opportunity to present the views and
    recommendations of the clinical research training community.

                                    ADDENDUM

     National Institutes of Health--National Center for Research Resources
                                     (NCRR)

                                          CTSA/GCRC ESTIMATE PER CURRENT MODEL
                                                  [Dollars in millions]
    ----------------------------------------------------------------------------------------------------------------
                                                                        Fiscal year     Fiscal year     Fiscal year
                         Cohort                             No.            2009            2010            2011
    ----------------------------------------------------------------------------------------------------------------
    Fiscal year 2006 Grants \1\.....................              12            $140            $140            $116
    Fiscal year 2007 Grants \1\.....................              12             120             121             121
    Fiscal year 2008 Grants \1\.....................              14             107             107             107
    Fiscal year 2009 Grants \1\.....................               5              36              36              36
    Fiscal year 2010 Grants \1\.....................               2  ..............              14              14
    Fiscal year 2011 Grants \1\.....................              15  ..............  ..............             100
                                                     ---------------------------------------------------------------
          Total, CTSA Grants........................              60             403             418             494CTSA Support Contract...........................  ..............               3               3               3
    K30 Recompetition...............................  ..............  ..............               5               1
                                                     ---------------------------------------------------------------
          Total, CTSAs..............................  ..............             406             426             497GCRCs...........................................  ..............              69              41               3      Total, CTSAs/IGCRCs.......................  ..............             475             467             500
    ----------------------------------------------------------------------------------------------------------------
    \1\ UL1, KL2, TL1 awards.

                                     CTSAI/GCRC ESTIMATE IF REQUESTED AMOUNT AWARDED
                                                  [Dollars in millions]
    ----------------------------------------------------------------------------------------------------------------
                                                                        Fiscal year     Fiscal year     Fiscal year
                         Cohort                             No.            2009            2010            2011
    ----------------------------------------------------------------------------------------------------------------
    Fiscal year 2006 Grants \1\.....................              12            $140            $140            $140
    Fiscal year 2007 Grants \1\.....................              12             158             158             158
    Fiscal year 2008 Grants \1\.....................              14             155             155             155
    Fiscal year 2009 Grants \1\.....................               5              50              50              50
    Fiscal year 2010 Grants \1\.....................               2  ..............              21              21
    Fiscal year 2011 Grants \1\.....................              15  ..............  ..............             142
                                                     ---------------------------------------------------------------
          Total, CTSA Grants........................              60             503             524         \2\ 666CTSA Support Contract...........................  ..............               3               3               3
    K30 Recompetition...............................  ..............  ..............               5               1
                                                     ---------------------------------------------------------------
          Total, CTSAs..............................  ..............             506             532             669GCRCs...........................................  ..............              69              41               3
                                                     ---------------------------------------------------------------
          Total, CTSAs/IGCRCs.......................  ..............             575             573             672
    ----------------------------------------------------------------------------------------------------------------
    \1\ UL1, KL2, TL1 awards.
    \2\ It would cost $666 million to fund 60 CTSAs at the amounts requested by the institutions, which is $166
      million more than the $500 million budget.

                                                       DIFFERENCE
                                                  [Dollars in millions]
    ----------------------------------------------------------------------------------------------------------------
                                                                        Fiscal year     Fiscal year     Fiscal year
                         Cohort                             No.            2009            2010            2011
    ----------------------------------------------------------------------------------------------------------------
    Fiscal year 2006 Grants \1\.....................              12  ..............  ..............         \2\ $24
    Fiscal year 2007 Grants \1\.....................              12              38             $37              37
    Fiscal year 2009 Grants \1\.....................              14             $48              48              48
    Fiscal year 2009 Grants \1\.....................               5              14              14              14
    Fiscal year 2010 Grants \1\.....................               2  ..............               7               7
    Fiscal year 2011 Grants \1\.....................              15  ..............  ..............              42
                                                     ---------------------------------------------------------------
          Total, CTSA Grants........................              60             100             106             172CTSA Support Contract...........................  ..............  ..............  ..............  ..............
    K30 Recompetition...............................  ..............  ..............  ..............  ..............
                                                     ---------------------------------------------------------------
          Total, CTSAs..............................  ..............             100             106             172GCRCs...........................................  ..............  ..............  ..............  ..............
                                                     ---------------------------------------------------------------
          Total, CTSAs/IGCDCs.......................  ..............             100             106             172
    ----------------------------------------------------------------------------------------------------------------
    \1\ UL1, KL2, TL1 awards.
    \2\ It would cost an additional $100 million in fiscal year 2009, $106 million in fiscal year 2010, and $172
      million in fiscal year 2011 to fund the CTSAs at the amounts requested by the institutions.

                                     ______

              Prepared Statement of The American Heart Association
        Despite considerable progress, heart disease, stroke, and other
    forms of cardiovascular disease remain major causes of permanent
    disability and our Nation's No. 1 and most costly killer, with a death
    every 37 seconds. Cardiovascular disease will cost our country a
    projected $475 billion in medical costs and lost productivity this
    year. Heart disease, alone, is our leading cause of death and stroke is
    our No. 3 killer.
        In the face of these staggering statistics, heart disease and
    stroke research, treatment and prevention programs remain woefully
    underfunded. For example, National Institutes of Health (NIH) invests
    only 4 percent of its budget on heart research and a mere 1 percent on
    stroke research. This level of funding is not commensurate with
    scientific opportunities, the number afflicted and the economic toll
    exacted on our Nation.
        Cardiovascular disease remains the No. 1 killer in every State and
    many preventable and treatable risk factors continue to escalate.
    Unfortunately, the Centers for Disease Control and Prevention (CDC) has
    been able to provide basic implementation awards to only 14 States
    through its Heart Disease and Stroke Prevention Program and only 20
    States are funded for CDC's WISEWOMAN, a heart disease and stroke
    screening program for low-income uninsured and underinsured females.
    Moreover, where you live could affect whether you survive a
    particularly deadly form of heart disease, sudden cardiac arrest. At
    present, only 12 States receive funding for the Health Resources and
    Services Administration's (HRSA) Rural and Community Access to
    Emergency Devices Program designed to save lives from sudden cardiac
    death.
        The American Heart Association (AHA) appreciates Congress providing
    hope to the 1 in 3 adults in the United States who live with the
    consequences of cardiovascular disease, with the enactment of the
    American Recovery and Reinvestment Act (ARRA) and the fiscal year 2009
    Omnibus Appropriations Act. The Association commends Congress for
    including $10 billion for the NIH and $1 billion for a Prevention and
    Wellness Fund in the ARRA. These are wise and prudent investments that
    will provide both a much needed boost to our Nation's economy and
    enhance health. Yet these funds represent a one-time infusion of
    resources. Stable and sustained funding is imperative to boost heart
    disease and stroke prevention and treatment.
         funding recommendations: investing in the health of our nation
        With numerous new and promising research opportunities on the
    horizon and with cardiovascular disease risk factors on the rise, now
    is the time to make a wise enhanced investment to prevent and treat
    America's No. 1 and most costly killer. If Congress fails to capitalize
    on progress against cardiovascular disease now, Americans will pay more
    in the future in lost lives and higher healthcare costs. Our
    recommendations listed below address these issues in a comprehensive
    but fiscally responsible way follow.
                            funding gap for the nih
        NIH research has revolutionized patient care and holds the key to
    finding new ways to prevent, treat, and cure cardiovascular disease,
    resulting in longer, healthier lives and reduced healthcare costs. NIH
    invests resources in every State and in 90 percent of congressional
    districts.
        The AHA Recommends.--AHA supports the President's campaign pledge
    to double the NIH budget over the next decade. We advocate for a fiscal
    year 2010 appropriation of $32.4 billion for NIH, a 7 percent increase
    over the fiscal year 2009 appropriation, representing the first
    installment to double the NIH budget by fiscal year 2020. Stable and
    sustained funding is needed to help secure a solid return on Congress'
    investment that has saved millions of lives. NIH supported research
    prevents and cures disease and generates economic growth, creates jobs
    and preserves the U.S. role as the world leader in pharmaceuticals and
    biotechnology. Each NIH grant is associated with approximately seven
    jobs.
     enhance funding for nih heart and stroke research: a proven and wise
                                   investment
        Death rates from coronary heart disease and stroke have each fallen
    by almost 30 percent since 1999. This decline is directly related to
    NIH heart and stroke research, with scientists on the verge of new and
    exciting discoveries that could lead to innovative treatments and even
    cures for heart disease and stroke. For instance, recent NIH research
    has shown that postmenopausal hormone therapy does not prevent heart
    disease and stroke, has defined the genetic basis of dangerous
    responses to vital blood-thinners, and funded early work of the 2007
    Nobel Prize winners in Physiology or Medicine for development of gene
    targeting technology.
        In addition to saving lives, NIH-supported research can cut
    healthcare costs. For example, the original NIH tPA drug trial resulted
    in a 10-year net $6.47 billion reduction in stroke healthcare costs.
    The Stroke Prevention in Atrial Fibrillation Trial 1 produced a 10-year
    net saving of $1.27 billion. But, despite such concrete returns on
    investments and other successes, NIH heart and stroke research
    continues to be disproportionately underfunded, with NIH spending only
    4 percent of its budget on heart research, and a mere 1 percent on
    stroke research. NIH funding for these diseases are not commensurate
    with scientific opportunities, the number afflicted, the increasing
    prevalence, and the economic toll exacted on our Nation.
       cardiovascular disease research: national heart, lung, and blood
                               institute (nhlbi)
        Cardiovascular disease research funding fails to keep pace with
    medical research inflation and cannot sufficiently support existing
    studies or permit investment in promising research opportunities. The
    sustained loss of purchasing power has reduced NHLBI's ability to
    support investigator-initiated research and has forced cuts in
    Institute programs. Cutbacks will limit the implementation of both the
    NHLBI general and cardiovascular-specific strategic plans. Studies that
    could be scaled back include, the translation of basic research on
    human behavior into real world ways to reduce obesity and promote
    cardiovascular health; research on genetic susceptibility to heart
    disease in the Framingham population followed for three generations,
    and additional research into the best methods for saving lives of
    sudden cardiac arrest sufferers.
       stroke research: national institute of neurological disorders and
                                 stroke (ninds)
        An estimated 795,000 Americans will suffer a stroke this year, and
    more than 137,000 will die. Many of the 6.5 million stroke survivors
    face physical and mental disabilities, emotional distress and huge
    costs--a projected $69 billion in medical expenses and lost
    productivity in 2009.
        The NINDS-sponsored Stroke Progress Review Group has issued a long-
    term, stroke research strategic plan. A variety of research initiatives
    have since been undertaken, but more funding is needed to fully
    implement the plan. The fiscal year 2009 estimate for NINDS stroke
    research falls about 60 percent short of the plan's target and
    additional funding is needed for programs such as:
      --Stroke Translational Research.--Translational studies are essential
            to providing cutting-edge stroke treatment, patient care and
            prevention. However, due to budget shortfalls, NINDS has been
            forced to scale back by 30 percent its Specialized Programs of
            Translational Research in Acute Stroke from a planned 10
            centers to only 7.
      --Genetic Repository.--NINDS could better understand genetic risk
            factors associated with stroke by helping more researchers
            contribute data and findings to an NIH-funded genetic
            repository and to study available samples.
      --Neurological Emergencies Treatment Trials Network.--NINDS has
            established a clinical research network of emergency medicine
            physicians, neurologists and neurosurgeons to develop more and
            improved treatments for acute neurological emergencies, such as
            strokes. However, the number of trials will be limited by
            available funding.
        The AHA Recommends.--AHA supports an fiscal year 2010 appropriation
    of $3.227 billion for the NHLBI; and $1.705 billion for the NINDS.
    These represent a 7 percent increase more than fiscal year 2009--
    comparable to the Association's recommended percentage increase for the
    NIH.
                          increase funding for the cdc
        Prevention is the best way to protect the health of Americans and
    reduce the economic burden of heart disease and stroke. However,
    effective prevention strategies and programs are not being implemented
    due to insufficient Federal resources.
        For example, despite the fact that cardiovascular disease remains
    the No. 1 killer in every State, CDC's Division for Heart Disease and
    Stroke Prevention funds only 14 States to implement programs to reduce
    risk factors for heart disease and stroke, improve emergency response
    and quality care, and end treatment disparities. Another 27 States
    receive funds for capacity building (planning); but, there are no funds
    for actual implementation and many of these States have been stalled in
    the planning phase for years--some for a decade.
        This division also administers the WISEWOMAN program that screens
    uninsured and underinsured low-income women ages 40 to 64 in 20 States
    for heart disease and stroke risk. They receive counseling, education,
    referral, and followup as needed. Since January 2000, more than 84,000
    women have been screened and more than 210,000 lifestyle interventions
    have been conducted. An estimated 94 percent of these women were found
    to have at least one risk factor or pre-condition for heart disease,
    stroke, or other forms of cardiovascular disease. This program should
    be expanded to the other 30 States and to screen more eligible women in
    currently funded States.
        The AHA Recommends.--AHA joins with the CDC Coalition in support of
    an appropriation of $8.6 billion for CDC core programs, including
    increases for the Heart Disease and Stroke Prevention and WISEWOMAN
    programs. Within that total, we recommend $74 million for the Heart
    Disease and Stroke Prevention Program, allowing CDC to: (1) add the
    nine unfunded States; (2) elevate up to 18 States with capacity
    building awards to basic program implementation; (3) continue to
    support the remaining funded States; (4) maintain the Paul Coverdell
    National Acute Stroke Registry; (5) increase the capacity for heart
    disease and stroke surveillance; and (6) provide additional support for
    prevention research and program evaluation. We advocates $37 million to
    expand WISEWOMAN to more States. During last year's national
    competition, 10 States received approved applications but were denied
    funding due to insufficient resources. And, we join with the Friends of
    the NCHS in recommending $137.5 million for NCHS and one-time funding
    of $15 million to modernize the vital statistics system.
      restore funding for rural and community access to emergency devices
                                 (aed) program
        About 92 percent of cardiac arrest victims die outside of a
    hospital. Receiving immediate CPR and the use of an AED can more than
    double your chance of survival. Communities with comprehensive AED
    programs have achieved survival rates of 40 percent or higher. The
    Rural and Community AED Program provides grants to States to buy and
    place AEDs and train lay rescuers and first responders to use them.
    During its first year, 6,400 AEDs were purchased, and placed and 38,800
    individuals were trained. Due to budget cuts, only 12 States receive
    resources for this program.
        The AHA Recommends.--For fiscal year 2010, AHA advocates restoring
    the Rural and Community AED Program to its fiscal year 2005 level of
    $8.927 million.
      increase funding for the agency for healthcare research and quality
                                     (ahrq)
        AHRQ develops scientific evidence to improve health and healthcare.
    Through its Effective Health Care Program, AHRQ supports research
    focused on outcomes, comparative effectiveness, and the appropriateness
    of pharmaceuticals, devices and healthcare services for conditions such
    as heart disease, stroke, and high blood pressure.
        On another front, AHRQ's health information technology (HIT) plan
    will help bring healthcare into the 21st century through more than $260
    million invested in more than 200 projects and demonstrations since
    2004. AHRQ and its partners identify challenges to HIT adoption and
    use; develop solutions and best practices; and produce tools that help
    hospitals and clinicians successfully integrate HIT. This work must
    continue as a key component to health reform.
        The AHA Recommends.--AHA joins with Friends of AHRQ in advocating
    for a $405 million in base funding for AHRQ. It will preserve AHRQ's
    current initiatives and get the agency on track to a base budget of
    $500 million by 2013.
                                   conclusion
        Cardiovascular disease continues to impose a deadly, disabling and
    costly burden on Americans. However, a robust funding increase for NIH,
    CDC and HRSA research, treatment, and prevention programs will continue
    to save lives and reduce rising healthcare costs. The AHA urges
    Congress to give serious consideration to our recommendations during
    the fiscal year 2010 congressional appropriations process. They are a
    wise investment for our Nation and the health and well-being of all
    Americans now and in future generations.
                                     ______

                   Prepared Statement of Advocate Health Care
                           introduction and overview
        Advocate Health Care (Advocate)--the largest integrated healthcare
    provider in Illinois--very much appreciates the opportunity to submit
    written testimony for the record regarding Federal funding for the
    title VII and title VIII programs of the Public Health Service Act.
    Advocate serves 3.1 million patients annually and has a presence in
    virtually every Illinois congressional district through the operation
    of more than 200 sites of care. Specifically, 9 acute care hospitals, 2
    children's hospitals, 4 Level I trauma centers (the State's highest
    designation in trauma care), a home healthcare company, and the
    region's largest medical group--in Illinois' 1st, 2nd, 3rd, 4th, 5th,
    6th, 7th, 8th, 9th, 10th, 13th and 14th Congressional Districts.
    Advocate also serves patients from--and employs people in the 11th and
    16th Congressional Districts of Illinois. As the second largest
    employer in the Chicagoland area, Advocate employs 28,000 individuals,
    including 7,000 nurses. More than 5,000 physicians are also affiliated
    with Advocate.
        Advocate maintains a long-standing commitment to supporting the
    nurses who work within the Advocate system and to increasing resources
    at the State and Federal level to bolster and expand Illinois' and the
    Nation's nursing workforce. High-quality, compassionate health
    professionals are critical to the delivery of care in the Advocate
    system. Without our 7,000 nurses--who work hard every day on behalf of
    patients and their families, our standard of care could not be achieved
    for the millions of people we serve throughout Illinois each year.
        Advocate joins with Members of Congress, national nursing
    organizations, health professional societies and coalitions, and the
    general public in being deeply concerned about the current and
    anticipated national shortages of nurses and other health professionals
    and their potential adverse impact on patient access to quality care.
    To that end, Advocate respectfully urges the House Labor, Health and
    Human Services, and Education, and Related Agencies Appropriations
    Subcommittee to provide $550 million in fiscal year 2010 funding for
    the title VII and title VIII programs of the Public Health Service Act
    to support and expand diversity within the Nation's healthcare
    workforce, and ensure that the Nation has the nurses and other health
    professionals it needs to provide quality care to the patients of today
    and tomorrow.
            the nursing shortage and the need for title viii funding
        According to an April 13, 2009 Wall Street Journal article, last
    summer, the nation was short approximately 125,000 nurses. The nurse
    faculty shortage is of serious concern, since it is widely recognized
    as a principal cause of the nursing shortage. The American Association
    of Colleges of Nursing reports that in 2008, nearly 50,000 qualified
    applicants were not able to matriculate in nursing school, ``due
    primarily to a shortage of faculty shortage and resource constraints.''
    Although the recent economic downturn has prompted some nurses, who
    were retired or otherwise not working, to return to the workforce, many
    communities across the nation still do not have enough nurses to work
    in their hospitals and nursing homes, or to provide care in home or
    ambulatory settings.
        The Health Resources and Services Administration (HRSA) estimates
    that, due to a combination of increased demand and the anticipated
    insufficient supply of registered nurses, the Nation will face a
    growing shortage in the years ahead. Specifically, the Nation will be
    short an estimated 275,215 nurses in 2015--a deficit that will grow to
    approximately 808,416 by 2020. Within Illinois, HRSA predicts that the
    State will be short an estimated 9,300 nurses in 2010 and 31,900 in
    2020. Since nearly 60 percent of all nurses are employed by hospitals,
    the national and State level nursing shortages will have a significant
    and disproportionate impact on hospitals and hospital systems,
    including Advocate.
        The Title VIII Nursing Workforce Development Programs, housed at
    HRSA, provide resources to support the education and training for
    entry-level and advanced practice nurses. Specifically, title VIII
    programs offer loans, scholarships, traineeships, and other support to
    tens of thousands of individuals each year. According to the Health
    Professions and Nursing Education Coalition (HPNEC), more than 50,000
    nursing students and nurses received support from title VIII in fiscal
    year 2008. However, it is important to note that the demand for such
    financial support far exceeds current resources. In fiscal year 2008,
    HRSA received 6,078 applications for the Nurse Education Loan Repayment
    Program, but only had the funds to award 435 of those applications.
    Also, in fiscal year 2008, HRSA received 4,894 applications for the
    Nursing Scholarship Program, but only had funding to support 172
    awards. As such, to ensure that the nation can educate, train, and
    deploy enough nurses to the communities most in need, Advocate urges
    the subcommittee to provide a significant increase to title VIII
    programs in fiscal year 2010.
             physician shortages and the need for title vii funding
        The title VII health professions programs, housed within HRSA,
    provide: loans, loan guarantees and repayments, and scholarships to
    students; and contracts and grants to nonprofit organizations and
    entities, as well as academic institutions. Program funding supports:
    (1) health professional training--with a focus on increasing minority
    representation in the healthcare workforce, and (2) myriad community-
    based programs, which seek to increase access to care for underserved
    individuals and communities in Illinois and across the nation. As the
    nation currently faces shortages of primary care and specialty
    physicians--shortfalls that are expected to worsen in the coming
    years--these programs play a critical role in bolstering the nation's
    health workforce and helping to ensure its diversity.
        Advocate is proud that from fiscal year 2003 to fiscal year 2006,
    Advocate Illinois Masonic Medical Center (AIMMC)--an urban, Level I
    trauma center serving primarily high-risk populations in medically
    underserved and ethnically diverse Chicago northside communities--
    received a total of more than $600,000 in funding from HRSA for its two
    residency programs--in family practice and dentistry. HRSA funding
    helped support the training of 23 primary care/family practice
    residents, approximately 40 percent of whom were ethnic minorities.
    This Federal funding of the AIMMC residency program helped develop
    dozens of physicians who chose to practice in primary care, many of
    whom specifically work in underserved communities. For example,
    graduates of the AIMMC family residency program have gone on to
    practice in rural health clinics, Federally Qualified Health Centers,
    Federal and State Health Professional Shortage Areas, the Indian Health
    Service, and HIV/AIDS primary care clinics. In addition, past HRSA
    funding also supported the AIMMC dental residency program, allowing the
    staffing of a mobile dental van that provides care to approximately 600
    individuals--primarily uninsured--who have limited access to dental
    providers and care.
        As you know, funding for the title VII programs was reduced by more
    than 50 percent from fiscal year 2005 to fiscal year 2006, and funding
    for the title VIII program was decreased by nearly 34 percent during
    the same period. Due to these significant cuts--coupled with modest
    increases in the subsequent years--there have not been adequate
    resources to continue to fund Advocate's residency programs. The lack
    of title VII and title VIII funding has had a significant impact on
    our--and other hospitals'--ability to train the next generation of
    physicians and dentists. Moreover, we are concerned that the Nation is
    not investing adequately in health professionals who have an interest
    in--and commitment to--working in underserved communities. Increased
    fiscal year 2010 funding for title VII will help ensure that our nation
    is making the investment necessary to have the educated, well-trained,
    and diverse health professional workforce to care for a growing
    population in need.
                fiscal year 2010 funding request and conclusion
        As the Congress works to increase access to healthcare for all
    Americans--a critical action we support--the number of individuals
    seeking care is anticipated to grow significantly. At the exact same
    time that demand for healthcare likely will rise, the Nation is facing
    a significant shortage of nurses, physicians, and other health
    professionals. Therefore, we urge the subcommittee to provide $550
    million to the title VII and title VIII programs of the Public Health
    Service Act to bolster the Nation's health workforce and ensure access
    to care for all in need. We thank the subcommittee for its
    consideration of our views and stand ready to be a resource to you on
    health workforce and other matters.
                                     ______

          Prepared Statement of The Ad Hoc Group for Medical Research
        The Ad Hoc Group for Medical Research, which is a coalition of more
    than 300 patient and voluntary health groups, medical and scientific
    societies, academic and research organizations, and industry, thanks
    and commends Congress for including the extraordinary investment in
    medical research through the National Institutes of Health (NIH) that
    was included as part of in the American Recovery and Reinvestment Act
    (ARRA, Public Law 111-5) as well as the $938 million increase in NIH
    funding in the Omnibus Appropriations Act for fiscal year 2009 (Public
    Law 111-8). In particular, we are deeply grateful to the subcommittee
    for its long-standing support of NIH. These are difficult times for our
    Nation and for people all around the globe, but the affirmation of
    science is the key to a better future is a strategic step forward.
        The partnership between NIH and America's scientists, medical
    schools, teaching hospitals, universities, and research institutions
    continues to serve as the driving force in this Nation's search for
    ever-greater understanding of the mechanisms of human health and
    disease, from which arise new diagnostics and treatments, and cures,
    and better ways to improve the health and quality of life for all
    Americans. These advances also contribute to the Nation's economic
    strength by creating skilled, high-paying jobs; new products and
    industries; and improved technologies.
        The recent history of the NIH budget has hindered scientific
    discovery and limited the capacity of a key engine for today's
    innovation-based economy. The additional funding in the ARRA and the
    fiscal year 2009 omnibus are critical first steps to returning the NIH
    to a course for even greater discovery. These investments give
    patients, their families and researchers renewed hope for the future,
    and will help ensure the success of America's medical research
    enterprise and leadership.
        The funding increases in the ARRA and the fiscal year 2009 omnibus
    will provide an immediate infusion of funds into the Nation's proven
    and highly competitive medical research enterprise to sustain the
    pursuit of improved diagnostics, better prevention strategies, and new
    treatments for many devastating and costly diseases as well as support
    innovative research ideas, state-of-the-art scientific facilities and
    instrumentation, and the scientists, technicians, laboratory personnel,
    and administrators necessary to maintain the enterprise. More
    importantly, these funds will reinvigorate this Nation's ability to
    produce the human and intellectual capital that will continue to drive
    scientific discovery, transform health, and improve the quality of life
    for all Americans.
        Moreover, we see this as the first step in renewing a national
    commitment to sustained, predictable growth in NIH funding, which we
    believe is an essential element in restoring and sustaining both
    national and local economic growth and vitality as well as maintaining
    this Nation's prominence as the world leader in medical research.
        President Obama has committed to increase Federal support for
    research, technology, and innovation so that America can lead the world
    in creating new advanced jobs and products. A key element of his
    strategy is to double Federal funding for basic research to ``foster
    home-grown innovation, help ensure the competitiveness of U.S.
    technology-based businesses, and ensure that 21st century jobs can and
    will grow in America.'' If America is to succeed in the information-
    based, innovation driven world-wide economy of the 21st century, we
    must recommit to long-term sustained and predictable growth in medical
    research funding.
        As a result of this subcommittee's prior investment in NIH, we have
    made critical advances in several key areas including:
      --Stem Cells.--Reprogramming skin cells from a patient with
            Parkinson's Disease into normal neurons that could be used to
            fight this degenerative disease.
      --Infectious Diseases.--Developing more effective antibodies, and
            ultimately vaccines, to fight lethal flu viruses before they
            become pandemic.
      --Cancer.--Launching the Cancer Genome Atlas as a partnership between
            the National Cancer Institute and the National Human Genome
            Research Institute to discover the genetic basis for various
            cancers.
        In addition, as a consequence of the investment over the past two
    decades in the human genome project and other areas of genetics, we are
    now entering an era of personalized medicine, which has the potential
    to transform healthcare through earlier diagnosis, more effective
    prevention and treatment of disease, and avoidance of drug side
    effects. For example, the same medication can help one patient and be
    ineffective for, or toxic to, another. By applying our greater
    understanding of how an individual's genetic make-up affects a response
    to specific drugs, we will increasingly know which patients will likely
    benefit from treatment and which will not benefit, or worse, be harmed.
    Cancer chemotherapy and the use of the anticoagulant Coumadin are good
    examples of how this might be applied.
        However, the discovery process--while it produces tremendous
    value--often takes a lengthy and unpredictable path. The talent base
    and infrastructure that we are creating needs to be maintained. Large
    fluctuations in funding will be disruptive to training, to careers,
    long range projects and ultimately to progress. The research engine
    needs a predictable, sustained investment in science to maximize our
    return.
        We must ensure that after the stimulus money is spent we do not
    have to dismantle our newly built capacity and terminate valuable, on-
    going research. In 2011 and beyond we need to be able to continue to
    advance the new directions initiated with ARRA support.
        The fiscal year 2009 omnibus and the ARRA provided $38.5 billion
    for NIH to provide more than 16,000 new research grants for live-saving
    research into diseases such as cancer, diabetes, and Alzheimer's.
    Keeping up with the rising cost of medical research in the 2010
    appropriations will help NIH begin to prepare for the ``post-stimulus''
    era. In 2011 and beyond we need to make sure that the total funding
    available to NIH does not decline and that we can resume a steady,
    sustainable growth that will enable us to achieve the President's goal
    of doubling our investment in basic research. Consistent with the
    President's vision, we respectfully urge this subcommittee to increase
    funding for NIH in fiscal year 2010 by at least 7 percent.
        The ravages of disease are many, and the opportunities for progress
    across all fields of medical science to address these needs are
    profound. The community appreciates that this subcommittee has always
    recognized that science is unpredictable and that it is difficult to
    know exactly which discoveries gained through basic research will
    foster the next medical advancement. There are many examples of areas
    where important therapies for one disease have resulted from
    investments in unrelated areas of research. Investing broadly in
    biomedical research is the key to ensuring the future of America's
    medical research enterprise and the health of her citizens.
        Thank you again for your leadership in improving the health and
    quality of life for all Americans.
                                     ______

                    Prepared Statement of the AIDS Institute
        Dear Chairman Harkin and members of the subcommittee: The AIDS
    Institute, a national public policy research, advocacy, and education
    organization, is pleased to comment in support of critical HIV/AIDS and
    Hepatitis programs as part of the fiscal year 2010 Labor, Health and
    Human Services, and Education, and Related Agencies appropriation
    measure. We thank you for your support of these programs over the
    years, and trust you will do your best to adequately fund them in the
    future in order to provide for and protect the health of the Nation.
                                    hiv/aids
        HIV/AIDS remains one of the world's worst health pandemics in
    history. Worldwide, some 33 million people are infected with this
    incurable infectious disease, and 7,400 new infections occur each day.
    Tragically, AIDS has already claimed the lives of more than 25 million.
    In the United States 583,298 people have died of AIDS. Last year, the
    CDC announced that its estimate of new infections per year is now
    56,300, which is 40 percent higher than previous estimates. That
    translates into a new infection every 9\1/2\ minutes. At the end of
    2007, an estimated 1.1 million people in the United States were living
    with HIV/AIDS.
        Persons of minority races and ethnicities are disproportionately
    affected by HIV/AIDS. African Americans, who make up 12 percent of the
    U.S. population, account for half of the HIV/AIDS cases. HIV/AIDS also
    disproportionately affects the poor, and about 70 percent of those
    infected rely on public healthcare financing.
        The U.S. Government has played a leading role in fighting HIV/AIDS,
    both here and abroad. The vast majority of the discretionary programs
    supporting HIV/AIDS efforts domestically are funded through your
    subcommittee. The AIDS Institute, working in coalition with other AIDS
    organizations, has developed funding request numbers for each of these
    domestic AIDS programs. We ask that you do your best to adequately fund
    them at the requested level.
        Below are the program requests and supporting explanation:

         CENTERS FOR DISEASE CONTROL AND PREVENTION--HIV PREVENTION AND
                                  SURVEILLANCE
                            [In millions of dollars]
    ------------------------------------------------------------------------
                                                                  Amount
    ------------------------------------------------------------------------
    Fiscal year 2009........................................             692
    Fiscal year 2010 President's budget request.............             745
    Fiscal year 2010 community request......................           1,570
    ------------------------------------------------------------------------

        As stated above, the Centers for Disease Control and Prevention
    (CDC) has increased the estimate of people infected each year by 40
    percent. New infections are particularly occurring in certain
    populations, such as the poor, African-Americans, men who have sex with
    men, Latinos, substance users, and the incarcerated. In order to
    address the specific needs of these populations and the increased
    number of people infected, CDC is going to need additional funding.
        The CDC has developed a professional judgment budget outlining what
    funding is necessary to improve HIV prevention efforts and reduce HIV
    transmission in the United States. The professional judgment budget
    called for an additional $877 million in funding over the next 5 years.
    With the additional funding the CDC estimates that by 2020 it could
    decrease the HIV transmission rate by 50 percent, reduce the number of
    people who do not know their status by 50 percent, and halve the
    disparities in the Black and Hispanic communities.
        This additional funding would be targeted toward: (1) Increasing
    HIV testing and the number of people who are reached by effective
    prevention programs; (2) developing new tools to fight HIV with
    scientifically proven interventions; and (3) improving systems to
    monitor HIV and related risk behaviors, and to evaluate prevention
    programs.
        Investing in prevention today will save money tomorrow. Every case
    of HIV that is prevented saves, on average, $1 million of lifetime
    treatment costs for HIV. The CDC estimates that the cost of treating
    the estimated 56,300 new HIV infections in 2006 will translate into
    $9.5 billion in annual future medical costs.

                          RYAN WHITE HIV/AIDS PROGRAMS
                           [In millions of dollars]
    ------------------------------------------------------------------------
                                                                  Amount
    ------------------------------------------------------------------------
    Fiscal year 2009........................................           2,238
    President's budget request..............................           2,292
    Community request.......................................           2,816
    ------------------------------------------------------------------------

        The centerpiece of the Government's response to caring and treating
    low-income people with HIV/AIDS is the Ryan White HIV/AIDS Program.
    Ryan White currently serves more than half and million low-income,
    uninsured, and underinsured people each year.
        In fiscal year 2009, the Program received an increase of $72
    million, or just 3.3 percent. This increase does not even cover the
    rate of inflation. In his fiscal year 2010 budget the President is
    proposing an increase of $54 million, or just 2.2 percent. This
    includes a $20 million increase, or only 2.5 percent, to the AIDS Drug
    Assistance Program. The AIDS Institute urges you to provide substantial
    funding increases to all parts of the Ryan White Program. Consider the
    following:
      --Caseload Levels are Increasing.--People are living longer due to
            lifesaving medications; there are more than 56,000 new
            infections each year; and increased testing programs, according
            to the CDC, will identify 12,000 to 20,000 new people infected
            with HIV each year. With rising unemployment, people are losing
            their employer-sponsored health coverage. All of this will
            necessitate the need for more Ryan White services and
            medications.
      --The price of healthcare, including medications, is increasing and
            State and local budgets are experiencing cutbacks due to the
            economic downturn. A recent survey by the National Alliance of
            State and Territorial AIDS Directors found that 50 percent of
            ADAP programs have experienced or will experience State funding
            decreases in fiscal year 2009.
      --There are significant numbers of people in the United States who
            are not receiving life-saving AIDS medications. An IOM report
            concluded that 233,069 people in the United States who know
            their HIV status do not have continuous access to Highly Active
            Antiretroviral Therapy.
        Specifically, The AIDS Institute requests the following funding
    levels for each part of the Program:
      --Part A provides medical care and vital support services for persons
            living with HIV/AIDS in the metropolitan areas most affected by
            HIV/AIDS. We request an increase of $103 million, for a total
            of $766.1 million.
      --Part B base provides essential services including diagnostic, viral
            load testing, and viral resistance monitoring and HIV care to
            all 50 States, DC, Puerto Rico, and the territories. We are
            requesting a $105.4 million increase, for a total of $514.2
            million.
      The AIDS Drug Assistance Program (ADAP) provides life-saving HIV drug
            treatment to more than 140,000 people. Due to a lack of
            funding, States have not been able to include all necessary
            drugs on their formularies, have limited eligibility and capped
            enrollment. In order to address the 8,472 new ADAP clients and
            drug cost increases, we are requesting an increase of $268.6
            million for a total of $1,083.6 million.
      --Part C provides early medical intervention and other supportive
            services to more than 248,000 people at more than 380 directly
            funded clinics. We are requesting a $66.4 million increase, for
            a total of $268.3 million.
      --Part D provides care to more than 84,000 women, children, youth,
            and families living with and affected by HIV/AIDS. This family-
            centered care promotes better health, prevents mother-to-child
            transmission, and brings hard-to-reach youth into care. We are
            requesting a $57.7 million increase, for a total of $134.6
            million.
      --Part F includes the AIDS Education and Training Centers (AETCs)
            program and the Dental Reimbursement program. We are requesting
            a $15.6 million increase for the AETC program, for a total of
            $50 million, and a $5.6 million increase for the Dental
            program, for a total of $19 million.
        The AIDS Institute supports increased funding for the Minority AIDS
    Initiative (MAI). MAI funds services nationwide that address the
    disproportionate impact that HIV has on communities of color. We are
    requesting a $200.5 million increase across these programs, for a total
    of $610 million.

                  NATIONAL INSTITUTES OF HEALTH--AIDS RESEARCH
                            [In billions of dollars]
    ------------------------------------------------------------------------
                                                                  Amount
    ------------------------------------------------------------------------
    Fiscal year 2009........................................            3.01
    President's budget request..............................            3.06
    Community request.......................................             3.5
    ------------------------------------------------------------------------

        Through the National Institutes of Health (NIH), research is
    conducted to understand HIV and its complicated mutations, discover new
    drug treatments, develop a vaccine and other prevention programs such
    as microbicides, and ultimately develop a cure. Much of this work at
    the NIH is done in cooperation with private funding. The critically
    important work performed by the NIH not only benefits those in the
    United States, but the entire world.
        This research has already helped in the development of many highly
    effective new drug treatments, prolonging the lives of millions of
    people. As neither a cure nor a vaccine exists, and patients continue
    to build resistance to existing medications, additional research must
    continue. NIH also conducts the necessary behavioral research to learn
    how HIV can be prevented best in various affected communities. We ask
    the subcommittee to fund critical AIDS research at the community
    requested level of $3.5 billion.
                          comprehensive sex education
        The President's proposed budget eliminates appropriated funding for
    abstinence-only until marriage programs and instead creates a Teen
    Pregnancy Prevention Program primarily for interventions that have gone
    through a rigorous evaluation to delay sexual activity, reduce teen
    pregnancy, or increase contraceptive use. We fully support the zeroing-
    out of Community Based Abstinence Education programs. However, we hope
    these new programs will be used to fund efforts to protect teen sexual
    health beyond the prevention of teen pregnancy. Messages to prevent
    teen pregnancy may not speak to all youth, particularly gay youth, who
    are at a high risk of HIV infection. We request that the $110 million
    in discretionary funds in the President's budget for the Teen Pregnancy
    Prevention Initiative be maintained and that the language be broadened
    to include HIV and STD prevention.
                           syringe exchange programs
        At least one-quarter of all reported AIDS cases in our country are
    attributed to injection drug use through the sharing of needles and
    syringes. Federal scientific studies have repeatedly demonstrated that
    syringe exchange programs reduce the transmission of HIV and other
    infectious diseases without increasing or encouraging the use of
    illicit drugs, and may even help reduce drug use by creating a point of
    entry for addiction treatment. Today, there are nearly 200 such
    programs operating in 38 States, DC, and Puerto Rico. Despite their
    proven effectiveness, there is a ban on the use of Federal funds for
    these programs. We urge you to lift the Federal funding ban on syringe
    exchange programs in fiscal year 2010.
                                viral hepatitis
        Viral Hepatitis, whether A, B, or C, is an infectious disease that
    also deserves increased attention by the Federal Government. According
    to the CDC, there are an estimated 800,000 to 1.4 million Americans
    chronically infected with Hepatitis B, and 46,000 new infections each
    year. An estimated 1.6 percent of Americans have been infected with
    Hepatitis C, of whom 3.2 million are chronically infected. It is
    believed that one quarter of those infected with HIV are co-infected
    with Hepatitis C.
        Given these numbers, we are disappointed the program is currently
    funded at a level that is substantially less than what it was funded in
    fiscal year 2003 and falls far short of what is needed. In the
    President's budget, funding for Hepatitis Prevention at the CDC is
    slated to receive a negligible increase of $51,000. Funds are needed to
    establish a program to lower the incidence of Hepatitis through
    education, outreach, and surveillance. We are requesting an increase of
    $31.7 million for the program, for a total of $50 million.
        The AIDS Institute asks that you give weight to our testimony as
    you consider the fiscal year 2010 appropriation bill.
                                     ______

     Prepared Statement of the American Indian Higher Education Consortium
        Summary of Requests.--Summarized below are the fiscal year 2010
    recommendations for the Nation's 36 Tribal Colleges and Universities
    (TCUs), covering three areas within the Department of Education and one
    in the Department of Health and Human Services (HHS), Administration
    for Children and Families' (ACF) Head Start Program.
                        department of education programs
    Higher Education Act (HEA) Programs
        Strengthening Developing Institutions.--Section 316 of title III-A,
    specifically supports TCUs through two separate grant programs: (a)
    formula funded development grants, and (b) competitive facilities/
    construction grants designed to address the critical facilities needs
    at TCUs. The TCUs request that the Subcommittee appropriate $32 million
    to support these two vital programs.
        Pell Grants.--TCUs urge the subcommittee to fund the Pell Grant
    Program at the highest possible level.
    Perkins Career and Technical Education Programs
        The TCUs urge the Subcommittee to appropriate $8.5 million for
    section 117 of the Carl D. Perkins Career and Technical Education
    Improvement Act, which supports our two Tribally Controlled
    Postsecondary Vocational Institutions: United Tribes Technical College
    and Navajo Technical College. Additionally, TCUs strongly support the
    Native American Career and Technical Education Program (NACTEP)
    authorized under section 116 of the act.
    Relevant Title IX Elementary and Secondary Education Act (ESEA)
            Programs
        Adult and Basic Education.--Although Federal funding for tribal
    adult education was eliminated in fiscal year 1996, TCUs continue to
    offer much needed adult education, GED, remediation and literacy
    services for American Indians, yet their efforts cannot meet the
    demand. The TCUs request that the subcommittee direct $5 million of the
    Adult Education State Grants appropriated funds to make awards to TCUs
    to support their ongoing and essential adult and basic education
    programs.
        American Indian Teacher and Administrator Corps.--The American
    Indian Teacher Corps and the American Indian Administrator Corps offer
    professional development grants designed to increase the number of
    American Indian teachers and administrators serving their reservation
    communities. The TCUs request that the subcommittee support these
    programs at $10 million and $5 million, respectively.
                                  hhs program
    TCUs Head Start Partnership Program (DHHS-ACF)
        TCUs are ideal partners to help achieve the goals of Head Start in
    Indian country. The TCUs are working to meet the mandate that Head
    Start teachers earn degrees in Early Childhood Development or a related
    discipline. The TCUs request that $5 million be designated for the TCU-
    Head Start Partnership program, to ensure the continuation of current
    programs and the resources needed to support additional TCU-Head Start
    Partnership programs.
                               background on tcus
        TCUs are accredited by independent, regional accreditation agencies
    and like all institutions of higher education, must undergo stringent
    performance reviews on a periodic basis to retain their accreditation
    status. In addition to college level programming, TCUs provide
    essential high school completion (GED), basic remediation, job
    training, college preparatory courses, and adult education programs.
    TCUs fulfill additional roles within their respective reservation
    communities functioning as community centers, libraries, tribal
    archives, career and business centers, economic development centers,
    public meeting places, and child and elder care centers. Each TCU is
    committed to improving the lives of its students through higher
    education and to moving American Indians toward self-sufficiency.
        TCUs provide access to higher education for American Indians and
    others living in some of the Nation's most rural and economically
    depressed areas. According to 2000 Decennial Census data, the annual
    per capita income of the U.S. population was $21,587. In contrast, the
    annual per capita income of Native Americans was $12,893 or about 40
    percent less. In addition to serving their student populations, TCUs
    offer a variety of much needed community outreach programs.
        These institutions, chartered by their respective tribal
    governments, were established in response to the recognition by tribal
    leaders that local, culturally-based institutions are best suited to
    help American Indians succeed in higher education. TCUs effectively
    blend traditional teachings with conventional postsecondary curricula.
    They have developed innovative ways to address the needs of tribal
    populations and are overcoming long-standing barriers to success in
    higher education for American Indians. Since the first TCU was
    established on the Navajo Nation just 40 years ago, these vital
    institutions have come to represent the most significant development in
    the history of American Indian higher education, providing access to,
    and promoting achievement among, students who may otherwise never have
    known postsecondary education success.
      justifications for fiscal year 2010 appropriations requests for tcus
    HEA
        The Higher Education Act Amendments Act of 1998 created a separate
    section (Sec. 316) within title III-A specifically for the Nation's
    TCUs. Programs under titles III and V of the act support institutions
    that enroll large proportions of financially disadvantaged students and
    that have low per-student expenditures. Tribal colleges, which are
    truly developing institutions, are providing access to quality higher
    education opportunities to some of the most rural, impoverished, and
    historically underserved areas of the country. A clear goal of HEA
    title III programs is ``to improve the academic quality, institutional
    management and fiscal stability of eligible institutions, in order to
    increase their self-sufficiency and strengthen their capacity to make a
    substantial contribution to the higher education resources of the
    Nation.'' The TCU title III program is specifically designed to address
    the critical, unmet needs of their American Indian students and
    communities, in order to effectively prepare them to succeed in a
    global, competitive workforce. The TCUs urge the subcommittee to
    appropriate $32 million in fiscal year 2010 for title III-A section
    316, an increase of $8.8 million more than fiscal year 2009. These
    funds will afford these developing institutions the resources necessary
    to continue their ongoing grant programs and address the needs of their
    historically underserved students and communities.
        The importance of Pell Grants to TCU students cannot be overstated.
    U.S. Department of Education figures show that the majority of TCU
    students receive Pell Grants, primarily because student income levels
    are so low and our students have far less access to other sources of
    financial aid than students at State-funded and other mainstream
    institutions. Within the TCU system, Pell Grants are doing exactly what
    they were intended to do--they are serving the needs of the lowest
    income students by helping them gain access to quality higher
    education, an essential step toward becoming active, productive members
    of the workforce. The TCUs urge the subcommittee to fund this critical
    program at the highest possible level.
               carl d. perkins career and technical education act
        Tribally-controlled Postsecondary Vocational Institutions.--Section
    117 of the Perkins Act provides operating funds for two of our member
    institutions: United Tribes Technical College in Bismarck, North
    Dakota, and Navajo Technical College in Crownpoint, New Mexico. The
    TCUs urge the subcommittee to appropriate $8.5 million for section 117
    of the act.
        Native American Career and Technical Education Program.--The Native
    American Career and Technical Education Program (NACTEP) under section
    116 of the Act reserves 1.25 percent of appropriated funding to support
    Indian vocational programs. The TCUs strongly urge the subcommittee to
    continue to support NACTEP, which is vital to the continuation of much
    needed career and technical education programs being offered at TCUs.
                  greater support of indian education programs
        American Indian Adult and Basic Education (Office of Vocational and
    Adult Education).--This program supports adult basic education programs
    for American Indians offered by TCUs, State and local education
    agencies, Indian tribes, institutions, and agencies. Despite a lack of
    funding, TCUs must find a way to continue to provide basic adult
    education classes for those American Indians that the present K-12
    Indian education system has failed. Before many individuals can even
    begin the course work needed to learn a productive skill, they first
    must earn a GED or, in some cases, even learn to read. The number of
    students in need of remedial education before embarking on their degree
    programs is considerable at TCUs. There is a broad need for basic adult
    educational programs and TCUs need adequate funding to support these
    essential activities. TCUs respectfully request that the subcommittee
    direct $5 million of the Adult Education State Grants appropriated
    funds to make awards to TCUs to help meet the ever increasing demand
    for basic adult education and remediation program services that exists
    on their respective reservations.
        American Indian Teacher/Administrator Corps (Special Programs for
    Indian Children).--American Indians are severely underrepresented in
    the teaching and school administrator ranks nationally. These
    competitive programs are designed to produce new American Indian
    teachers and school administrators for schools serving American Indian
    students. These grants support recruitment, training, and in-service
    professional development programs for Indians to become effective
    teachers and school administrators and in doing so become excellent
    role models for Indian children. We believe that the TCUs are ideal
    catalysts for these two initiatives because of their current work in
    this area and the existing articulation agreements they hold with 4-
    year degree awarding institutions. The TCUs request that the
    subcommittee support these two programs at $10 million and $5 million,
    respectively, to increase the number of qualified American Indian
    teachers and school administrators in Indian Country.
                               hhs/acf/head start
        TCUs Head Start Partnership Program.--The TCU-Head Start
    Partnership has made a lasting investment in our Indian communities by
    creating and enhancing associate degree programs in Early Childhood
    Development and related fields. Graduates of these programs help meet
    the degree mandate for all Head Start program teachers. More
    importantly, this program has afforded American Indian children Head
    Start programs of the highest quality. A clear impediment to the
    ongoing success of this partnership program is the erratic availability
    of discretionary funds made available for the TCU-Head Start
    Partnership. In fiscal year 1999, the first year of the program, some
    colleges were awarded 3-year grants, others 5-year grants. In fiscal
    year 2002, no new grants were awarded. In fiscal year 2003, funding for
    eight new TCU grants was made available, but in fiscal year 2004, only
    two new awards could be made because of the lack of adequate funds. The
    President's February 26, 2009 budget summary includes an additional $1
    billion to improve and expand Head Start. The TCUs request that the
    subcommittee direct the Head Start Bureau to designate $5 million, of
    the more than $7.2 billion included in the President's budget, to fund
    the TCU-Head Start Partnership program, to ensure that this critical
    program can continue and expand so that all TCUs have the opportunity
    to participate in the TCU-Head Start Partnership program.
                                   conclusion
        TCUs are providing access to higher education opportunities to many
    thousands of American Indians and essential community services and
    programs to many more. The modest Federal investment in TCUs has
    already paid great dividends in terms of employment, education, and
    economic development, and continuation of this investment makes sound
    moral and fiscal sense. TCUs need your help if they are to sustain and
    grow their programs and achieve their missions to serve their students
    and communities.
        Thank you again for this opportunity to present our funding
    recommendations. We respectfully ask the members of the subcommittee
    for their continued support of the Nation's TCUs and full consideration
    of our fiscal year 2010 appropriations needs and recommendations.
                                     ______

         Prepared Statement of the Association of Independent Research
                                   Institutes
        The Association of Independent Research Institutes (AIRI)
    respectfully submits this written testimony for the record to the
    Senate Appropriations Subcommittee on Labor, Health and Human Services,
    Education, and Related Agencies. AIRI appreciates the commitment that
    the members of this subcommittee have made to biomedical research
    through your strong support for the National Institutes of Health
    (NIH), and recommends that you maintain this support for NIH in fiscal
    year 2010 by providing the agency with at least a 7 percent increase
    more than fiscal year 2009.
        AIRI is a national organization of 90 independent, nonprofit
    research institutes that perform basic and clinical research in the
    biological and behavioral sciences. AIRI institutes vary in size, with
    budgets ranging from a few million to hundreds of millions of dollars.
    In addition, each AIRI member institution is governed by its own
    independent board of directors, which allows our members to focus on
    discovery based research while remaining structurally nimble and
    capable of adjusting their research programs to emerging areas of
    inquiry. Researchers at independent research institutes consistently
    exceed the success rates of the overall NIH grantee pool, and receive
    about 10 percent of NIH's peer-reviewed, competitively awarded
    extramural grants. On average, AIRI member institutes receive a total
    of $1.6 billion in extramural grants from NIH in any given year.
        Through passage of the American Recovery and Reinvestment Act
    (ARRA) and the Omnibus Appropriations Act for fiscal year 2009, the
    administration and Congress have taken critical steps to jump start the
    Nation's economy. Simultaneously, Congress is advancing and
    accelerating the biomedical research agenda in this country by focusing
    on scientific opportunities to address public health challenges. NIH
    now has the ability to fund a record number of research grants, with
    special emphasis on groundbreaking projects in areas that show the
    greatest potential for improving health, including genetic medicine,
    clinical research, and health disparities. In addition, NIH is also
    funding construction projects and providing support for equipment and
    instrumentation.
        NIH is responding to its charge of stimulating the economy through
    job creation by supporting new scientists, construction workers, and
    suppliers. NIH is also supporting the next generation of biomedical
    research through cross-cutting, interdisciplinary initiatives such as
    those supported in the NIH Roadmap, the NIH Neuroscience Blueprint, the
    Clinical and Translational Science Award program, and the Genes,
    Environment and Health Initiative. Independent research institutes are
    involved extensively in these initiatives and will be beneficiaries of
    ARRA funds, making them an important and vital component of the overall
    U.S. medical research enterprise. Therefore, independent research
    institutes are positioned to help Congress achieve its goal of
    improving the quality of life for all Americans.
        However, the discovery process--while it produces tremendous
    value--often takes a lengthy and unpredictable path. The infrastructure
    that we are creating needs to be maintained. Large fluctuations in
    funding will be disruptive to training, to careers, long-range projects
    and ultimately to progress. The research engine needs a predictable,
    sustained investment in science to maximize our return.
        We must ensure that after the stimulus money is spent we do not
    have to dismantle our newly built capacity and terminate valuable, on-
    going research. In 2011 and beyond we need to be able to continue to
    advance the new directions charted with the ARRA support.
        Keeping up with the rising cost of medical research in the 2010
    appropriations will help NIH begin to prepare for the ``post-stimulus''
    era. In 2011 and beyond we need to make sure that the total funding
    available to NIH does not decline and that we can resume a steady,
    sustainable growth that will enable us to complete the President's
    vision of doubling our investment in basic research, which is why we
    are respectfully urging this subcommittee to increase funding for NIH
    in fiscal year 2010 by at least 7 percent.
                               airi's commitment
    Pursuing New Knowledge
        The United States model for conducting biomedical research, which
    involves supporting scientists at universities, medical centers, and
    independent research institutes, provides an effective approach to
    making fundamental discoveries in the laboratory and translating them
    into medical advances that save lives. AIRI member institutes are
    private, stand-alone research centers that set their sights on the vast
    frontiers of medical science, specifically focused on pursuing
    knowledge about the biology and behavior of living systems and to apply
    that knowledge to extend healthy life and reduce the burdens of illness
    and disability.
    Providing Efficiency and Flexibility
        AIRI member institutes' smaller size and greater flexibility
    provide an environment that is particularly conducive to creativity and
    innovation. In addition, independent research institutes possess a
    unique versatility/culture that encourages them to share expertise,
    information, and equipment across their institutes and elsewhere, which
    helps to minimize bureaucracy and increase efficiency when compared to
    larger degree-granting academic universities.
    Supporting Young Researchers
        While the primary function of AIRI institutes is research, most are
    strongly involved in training the next generation of biomedical
    researchers and ensuring that a pipeline of promising researchers are
    prepared to make significant and potentially transformative discoveries
    in a variety of areas.
        AIRI would like to thank the subcommittee for its important work to
    ensure the health of the Nation, and we appreciate this opportunity to
    present funding recommendations concerning NIH in the fiscal year 2010
    appropriations bill. AIRI looks forward to working with Congress to
    carry out the research that will lead to improving the health and
    quality of life for all Americans.
                                     ______

      Prepared Statement of the Association of Maternal and Child Health
                                    Programs
        Chairman Harkin and distinguished subcommittee members: I am
    grateful for this opportunity to submit written testimony on behalf of
    the Association of Maternal & Child Health Programs (AMCHP), our
    members, and the millions of women and children that are served by the
    title V Maternal and Child Health Services Block Grant. My name is Dr.
    Phyllis Sloyer and I am the current president of AMCHP, as well a
    Division Director at the Florida Department of Health. I am asking the
    subcommittee to support full funding for the title V Maternal and Child
    Health Services Block Grant at its authorized level of $850 million for
    Federal fiscal year 2010.
        To help illustrate the importance of title V MCH funding, I want to
    begin by sharing the story of a girl from Iowa who was helped by title
    V services.
        Cora is a girl who was born 34 weeks prematurely. She was first
    seen at a Child Health Specialty Clinic when she was only 3 weeks of
    age. While at the clinic, she was diagnosed with, plagiocephaly also
    sometimes referred to a ``flat head syndrome''. This problem occurs
    when a portion of an infant's skull becomes flattened due to pressure
    from outside forces and is not uncommon in premature infants. Workers
    at the clinic provided the new family with vital information on the
    disorder and what to expect. Cora was able to be seen by a pediatrician
    via telemedicine and was able to obtain a referral to see specialists
    in the treatment of plagiocephal. Cora is now 20 months old and likes
    to go to the local park and ride the merry-go-round. This same clinic
    that helped Cora and her family is supported by the Title V MCH Block
    Grant and would not be able to remain open without the funds and
    support that title V funds offer. It is a great thing that families can
    come to a clinic close to their home, or be seen using health
    technology and be provided a complete physical, neurological,
    developmental evaluation for their kids.
        This is just one example of the literally thousand of children--
    children with special healthcare needs and pregnant women that are
    served by title V programs in Chairman Harkin's State alone. The MCH
    Block Grant supports a similar network in my home State of Florida, and
    none of this could happen without the Title V MCH Block Grant funding.
        Title V of the Social Security Act was created during the Great
    Depression to ``improve the health of all women and children.'' The MCH
    Block Grant is a celebrated example of an effective Federal and State
    partnership with a common goal of improving the health of all mothers
    and children, including those children with special healthcare needs.
    It is also at the forefront of promoting family-centered care in all of
    its work. But we are losing ground fast and we believe it is time to go
    back to the roots of title V and recommit ourselves to truly improving
    the health of our Nation's women and children by fully investing in the
    MCH Block Grant.
        Despite major advances in medicine, technology, and our healthcare
    system, America still faces huge challenges to improving maternal and
    child health outcomes and addressing the needs of very vulnerable
    children.
        Reductions in maternal and infant mortality have stalled in recent
    years and rates of preterm and low-birth-weight births have increased
    over the last decade. As we sit here today, the United States ranks
    29th in infant mortality rates when compared to other nations. Every 18
    minutes a baby in America dies before his or her first birthday. Each
    day in America we lose 12 babies due to a sudden unexpected infant
    death. There are places in this country where the African American
    infant mortality rate is double, and in some places even triple, the
    rate for whites. Preventable injuries remain the leading cause of death
    for all children, we are failing to adequately screen all young
    children for developmental concerns and childhood obesity has reached
    epidemic proportions, threatening to reverse a century of progress in
    extending life expectancy.
        Sadly, there are gaps between what a family needs and actually
    receives for a child with a special need. Out of pocket healthcare
    costs are increasing and we are erasing gains we made in supporting
    effective services for children with special needs and their families.
    Currently, only 50 percent of these children receive comprehensive care
    within the context of a medical home and less than 20 percent of youth
    with special needs are able to find an adult healthcare provider who
    can appropriately care for them.
        State programs, funded through MCH Block Grant dollars, are key to
    reversing this picture. Considering these and many other urgent health
    needs, AMCHP asks for your leadership in fully funding the MCH Block
    Grant at $850 million for fiscal year 2010.
        AMCHP urges Congress to recognize the need to revitalize resources
    for States and their partners to reverse the trends and continue this
    critical work. We have a track record of demonstrating that we make a
    positive difference and are fully accountable for the funds that we
    receive. Fully funding the MCH Block Grant is an effective and
    efficient way to invest in our Nation's women, children, and families.
        The Office of Management and Budget found that MCH Block Grant-
    funded programs deliver results and decrease the infant mortality rate,
    prevent disabling conditions, increase the number of children
    immunized, increase access to care for uninsured children, and improve
    the overall health of mothers and children. Close coordination with
    other health programs assures that funding is maximized and services
    are not duplicated.
        Our results are available to the public through a national Web site
    known as the Title V Information System. Such a system is remarkably
    rare for a Federal program and we are proud of the progress we have
    made.
        However, despite the increasing demand for maternal and child
    health services, reductions to the MCH Block Grant threaten the ability
    of programs to carry out their vital work. As States continue to face
    increasing economic hardship, more women and children will seek
    services through MCH Block Grant funded programs. Due to years of
    reduced investment, the MCH Block Grant is at its lowest funding level
    since 1993, $662 million, meaning States again are being asked to serve
    additional people with less.

        Now, as economic troubles increase demand for health services,
    State MCH programs desperately need additional resources to:
      --increase outreach and screening services to identify and link women
            and children to available healthcare services;
      --assure coordination of those services and assist new parents
            through efforts such as expanded home visitation programs; and
      --deliver essential prevention and health promotion services to make
            sure that every mom has a healthy pregnancy; every child has
            the opportunity for a healthy birth and strong start in life;
            and every child with special healthcare needs receives ongoing
            comprehensive care within a medical home.
        Crucial MCH activities are also supported by title V under the
    Special Projects of Regional and National Significance (SPRANS)
    program, including MCH research, training, hemophilia diagnostic and
    treatment centers, and MCH improvement projects that develop and
    support a broad range of strategies. The SPRANS investment drives
    innovation for MCH programs and is an important part of the Title V MCH
    Block Grant.
        Mr. Chairman and distinguished members, in closing I ask you to
    imagine with me an America in which every child in the United States
    has the opportunity to live until his or her first birthday; a Nation
    where our Federal and State partnership has effectively moved the
    needle on our most pressing maternal and child health issues. Imagine a
    day when we are celebrating significant reductions or even the total
    elimination of health disparities by creatively solving our most urgent
    maternal and child health challenges. The MCH Block Grant aims to do
    just that--using resources effectively to improve the health of all of
    America's women and children.
        I want to close with one more story from a parent in my State that
    I think illustrates the personal impact of Title V MCH Block Grant
    funds.
        My daughter Ashley continues to be at risk for a detached retina
    with myopia of the eye. Title V Children and Youth with Special Health
    Care Needs has been instrumental in providing medically necessary
    funding for the type of eyeglasses that she needs in order to be able
    to see and have some quality of life as an adolescent. There are
    medications that she needs to be able to control her executive
    functions, her impulses and her motor coordination in order to be able
    to function in school that I would not be able to afford as a parent.
    As a parent it would be devastating if she could not go to school which
    increases her chances of being able to transition into work and/or
    higher education.
                                     ______

             Prepared Statement of the American Nurses Association
        The American Nurses Association (ANA) appreciates this opportunity
    to comment on fiscal year 2010 appropriations for nursing education,
    workforce development, and research programs. Founded in 1896, ANA is
    the only full-service national association representing registered
    nurses (RNs). Through our 51 constituent member associations, ANA
    represents RNs across the Nation in all practice settings.
        The ANA gratefully acknowledges this subcommittee's history of
    support for nursing education and research. We appreciate your
    continued recognition of the important role nurses play in the delivery
    of quality healthcare services. This testimony will give you an update
    on the status of the nursing shortage, its impact on the Nation, and
    the outlook for the future.
                           the nursing shortage today
        The nursing shortage is far from solved. Here are a few quick
    facts:
      --The American Hospital Association reported that hospitals needed
            116,000 more RNs to fill immediate vacancies in July 2007.
            Hospitals report that this vacancy rate is hampering the
            ability to provide emergency care.
      --The Bureau of Labor Statistics reports that registered nursing will
            have remarkable job growth in the time period spanning 2006-
            2016. During this time, the healthcare system will require more
            than 1 million new nurses.
      --The Health Resources and Services Administration (HRSA) projects
            that the supply of nurses in America will fall 26 percent (more
            than 1 million nurses) below requirements by the year 2020. In
            year 2020, Wisconsin's demand for full-time RNs will outstrip
            the supply by 20 percent (a shortage of 10,200 RNs). New York's
            shortage will reach 39 percent (54,200 RNs) and Ohio will have
            a 30 percent shortage (34,000 RNs). California's demand will
            outstrip its supply by 45 percent (116,600 RNs).
        This growing nursing shortage is having a detrimental impact on the
    entire healthcare system. Numerous studies have shown that nursing
    shortages contribute to medical errors, poor patient outcomes, and
    increased mortality rates. A study published in the January/February
    2006 issue of Health Affairs showed that hospitals could avoid 6,700
    deaths per year by increasing the amount of RN care provided to their
    patients. This study, ``Nurse Staffing in Hospitals: Is There a
    Business Case for Quality?'' by Jack Needleman, Peter Buerhaus, et al.
    also revealed that hospitals are currently providing 4 million days
    worth of inpatient care annually to treat avoidable patient
    complications associated with a shortage of RN care.
        Research published in the October 23, 2002, Journal of the American
    Medical Association also demonstrated that more nurses at the bedside
    could save thousands of patient lives each year. In reviewing more than
    232,000 surgical patients at 168 hospitals, researchers from the
    University of Pennsylvania concluded that a patient's overall risk of
    death rose roughly 7 percent for each additional patient above four
    added to a nurse's workload.
        A Joint Commission on the Accreditation of Healthcare Organizations
    study published in 2002 shows that the shortage of nurses contributes
    to nearly a quarter of all unexpected incidents that kill or injure
    hospitalized patients.
                     nursing workforce development programs
        Federal support for the Nursing Workforce Development Programs
    contained in title VIII of the Public Health Service Act is
    unduplicated and essential. The 107th Congress recognized the
    detrimental impact of the developing nursing shortage and passed the
    Nurse Reinvestment Act (Public Law 107-205). This law improved the
    title VIII Nursing Workforce Development programs to meet the unique
    characteristics of today's shortage. This achievement holds the promise
    of recruiting new nurses into the profession, promoting career
    advancement within nursing, and improving patient care delivery.
    However, this promise cannot be met without a significant investment.
    Prior to the release of President Obama's proposed budget for fiscal
    year 2010, ANA was strongly advocating Congress to increase funding for
    title VIII programs by at least $44 million to a total of $215 million.
    Now that President Obama is requesting $263 million for title VIII
    programs, we are urging the subcommittee to support this request and
    fund title VIII programs at $263 million.
        Current funding levels are clearly failing to meet the need. In
    fiscal year 2008, the HRSA was forced to turn away 92.8 percent of the
    eligible applicants for the Nurse Education Loan Repayment Program
    (NELRP), and 53 percent of the eligible applicants for the Nursing
    Scholarship Program (NSP) due to a lack of adequate funding. These
    programs are used to direct RNs into areas with the greatest need--
    including departments of public health, community health centers, and
    disproportionate share hospitals.
        In 1973, Congress appropriated $160.61 million to title VIII
    programs. Inflated to today's dollars, this appropriation would equal
    $763.52 million, more than four times the fiscal year 2009
    appropriation. Certainly, today's shortage is more dire and systemic
    than that of the 1970's; it deserves an equivalent response.
        Title VIII includes the following program areas:
        Nursing Education Loan Repayment Program and Scholarships
    (NELRP).--This line item is comprised of the NELRP and the NSP. In
    fiscal year 2009, the NELRP and the NSP received $37 million.
        The NELRP repays up to 85 percent of a RN's student loans in return
    for full-time practice in a facility with a critical nursing shortage.
    The NELRP nurse is required to work for at least 2 years in a
    designated facility, during which time the NELRP repays 60 percent of
    the RN's student loan balance. If the nurse applies and is accepted for
    an optional third year, an additional 25 percent of the loan is repaid.
        The NELRP boasts a proven track record of delivering nurses to
    facilities hardest hit by the nursing shortage. HRSA has given NELRP
    funding preference to RNs who work in departments of public health,
    disproportionate share hospitals, skilled nursing facilities, and
    federally designated health centers. However, lack of funding has
    hindered the full implementation of this program. In fiscal year 2008,
    92.8 percent of applicants willing to immediately begin practicing in
    facilities hardest hit by the shortage were turned away from this
    program due to lack of funding.
        The NSP offers funds to nursing students who, upon graduation,
    agree to work for at least 2 years in a healthcare facility with a
    critical shortage of nurses. Preference is given to students with the
    greatest financial need. Like the loan repayment program, the NSP has
    been stunted by a lack of funding. In fiscal year 2008, HRSA received
    3,039 applications for the nursing scholarship. Due to lack of funding,
    a mere 177 scholarships were awarded. Therefore, 2,862 nursing students
    (94 percent) willing to work in facilities with a critical shortage
    were denied access to this program.
        Nurse Faculty Loan Program.--This program establishes a loan
    repayment fund within schools of nursing to increase the number of
    qualified nurse faculty. Nurses may use these funds to pursue a
    master's or doctoral degree. They must agree to teach at a school of
    nursing in exchange for cancellation of up to 85 percent of their
    educational loans, plus interest, over a 4-year period. In fiscal year
    2009, this program received $11.5 million.
        This program is vital given the critical shortage of nursing
    faculty. America's schools of nursing can not increase their capacity
    without an influx of new teaching staff. Last year, schools of nursing
    were forced to turn away tens of thousands of qualified applicants due
    largely to the lack of faculty. In fiscal year 2008, HRSA funded 95
    faculty loans.
        Nurse Education, Practice, and Retention Grants.--This section is
    comprised of many programs designed to support entry-level nursing
    education and to enhance nursing practice. All together, the Nurse
    Education, Practice, and Retention Grants received $37.3 million in
    fiscal year 2009.
        The education grants are designed to expand enrollments in
    baccalaureate nursing programs; develop internship and residency
    programs to enhance mentoring and specialty training, and; provide new
    technologies in education including distance learning.
        Retention grant areas include career ladders and improved patient
    care delivery systems. The career ladders program supports education
    programs that assist individuals in obtaining the educational
    foundation required to enter the profession, and to promote career
    advancement within nursing. Enhancing patient care delivery system
    grants are designed to improve the nursing work environment. These
    grants help facilities to enhance collaboration and communication among
    nurses and other healthcare professionals, and to promote nurse
    involvement in the organizational and clinical decisionmaking processes
    of a healthcare facility. These best practices for nurse administration
    have been identified by the American Nurse Credentialing Center's
    Magnet Recognition Program. These practices have been shown to double
    nurse retention rates, increase nurse satisfaction, and improve patient
    care.
        Nursing Workforce Diversity.--This program provides funds to
    enhance diversity in nursing education and practice. It supports
    projects to increase nursing education opportunities for individuals
    from disadvantaged backgrounds--including racial and ethnic minorities,
    as well as individuals who are economically disadvantaged. In fiscal
    year 2008, 85 applications were received for workforce diversity
    grants, 51 were funded. In fiscal year 2009, these programs received
    $16 million.
        Advanced Nurse Education.--Advanced practice registered nurses
    (APRNs) are nurses who have attained advanced expertise in the clinical
    management of health conditions. Typically, an APRN holds a master's
    degree with advanced didactic and clinical preparation beyond that of
    the RN. Most have practice experience as RNs prior to entering graduate
    school. Practice areas include, but are not limited to: anesthesiology,
    family medicine, gerontology, pediatrics, psychiatry, midwifery,
    neonatology, and women's and adult health. Title VIII grants have
    supported the development of virtually all initial State and regional
    outreach models using distance learning methodologies to provide
    advanced study opportunities for nurses in rural and remote areas. In
    fiscal year 2008, 7,650 advanced education nurses were supported
    through these programs. In fiscal year 2009, these programs received
    $64.4 million.
        These grants also provide traineeships for masters and doctoral
    students. Title VIII funds more than 60 percent of U.S. nurse
    practitioner education programs and assists 83 percent of nurse
    midwifery programs. more than 45 percent of the nurse anesthesia
    graduates supported by this program go on to practice in medically
    underserved communities. A study published last year in the Journal of
    Rural Health showed that 80 percent of the nurse practitioners who
    attended a program supported by title VIII chose to work in a medically
    underserved or health profession shortage area after graduation.
        Comprehensive Geriatric Education Grants.--This authority awards
    grants to train and educate nurses in providing healthcare to the
    elderly. Funds are used to train individuals who provide direct care
    for the elderly, to develop and disseminate geriatric nursing
    curriculum, to train faculty members in geriatrics, and to provide
    continuing education to nurses who provide geriatric care. In fiscal
    year 2009, these grants received 4.5 million.
        The growing number of elderly Americans and the impending
    healthcare needs of the baby boom generation make this program
    critically important. In fiscal year 2006, HRSA continued 8 previously
    awarded grants and awarded 11 new ones.
                 national institute of nursing research (ninr)
        ANA also urges the subcommittee to increase funding for the NINR,
    one of the Institutes at the National Institutes of Health (NIH). The
    Institute's research focus transcends disciplines to address issues of
    health management, symptom management, and caregiving; health promotion
    and disease prevention; end-of-life care; technology integration; and
    research capacity development. This research is integral to improving
    the effectiveness of nursing care. Advances in nursing care arising
    from behavioral and biomedical research have shown excellent progress
    in reducing healthcare costs. Research programs supported by NINR
    address a number of critical public health and patient care questions.
    The cross-discipline research is driven by real and immediate problems
    currently facing patients and their families.
        Recent NINR funded studies have shown that inadequate nurse
    staffing increases risks for patients; coping skills training improves
    teens' self-management of diabetes; a healthcare team helps reduce high
    blood pressure among inner-city black men; a community-based program
    improves self-management of arthritis among older Hispanics; home
    nursing visits benefit low-income mothers and their children; and
    transitional care improves outcomes for elders after leaving the
    hospital. NINR is leading the NIH research on end-of-life and
    palliative care. NINR is also the lowest-funded Institute at NIH. In
    fiscal year 2009, NINR received $141.88 million. ANA recommends $178
    million, or a 25 percent increase more than fiscal year 2009, in fiscal
    year 2010 NINR funding.
                                   conclusion
        While ANA appreciates the continued support of this subcommittee,
    we are concerned that title VIII funding levels have not been
    sufficient to address the growing nursing shortage. The nursing
    shortage will continue to worsen if significant investments are not
    made. Recent efforts have shown that aggressive and innovative
    recruitment efforts can help avert the impending nursing shortage--if
    they are adequately funded.
        ANA asks you to meet today's shortage with a relatively modest
    investment of $263 million in title VIII programs. Additionally, an
    investment of $178 million in the NINR will help assure that nurses are
    equipped with the latest information and research needed to provide the
    best patient care possible.
                                     ______

             Prepared Statement of the American National Red Cross
        Chairman Tom Harkin, Ranking Member Thad Cochran, and members of
    the subcommittee, the American Red Cross and the United Nations
    Foundation appreciate the opportunity to submit testimony in support of
    measles control activities of the U.S. Centers for Disease Control and
    Prevention (CDC). The American Red Cross and the United Nations
    Foundation recognize the leadership that Congress has shown in funding
    CDC for these essential activities. We sincerely hope that Congress
    will continue to support the CDC during this critical period in measles
    control.
        In 2001, CDC--along with the American Red Cross, the United Nations
    Foundation, the World Health Organization (WHO), and UNICEF--became one
    of the spearheading partners of the Measles Initiative, a partnership
    committed to reducing measles deaths globally. The current U.N. goal is
    to reduce measles deaths by 90 percent by 2010 compared to 2000
    estimates. The Measles Initiative is committed to reaching this goal by
    proving technical and financial support to governments and communities
    worldwide.
        The Measles Initiative has achieved ``spectacular'' \1\ results by
    supporting the vaccination of more than 600 million children. Largely
    due to the Measles Initiative, global measles mortality dropped 74
    percent, from an estimated 750,000 deaths in 2000 to 197,000 in 2007.
    During this same period, measles deaths in Africa fell by 89 percent,
    from 395,000 to 45,000.
    ---------------------------------------------------------------------------
        \1\ The Lancet, Volume 8, page 13 (January 2008).

        Working closely with host governments, the Measles Initiative has
    been the main international supporter of mass measles immunization
    campaigns since 2001. The Initiative mobilized more than $670 million
    and provided technical support in more than 60 developing countries on
    vaccination campaigns, surveillance, and improving routine immunization
    services. From 2000 to 2007, an estimated 3.6 million measles deaths
    were averted as a result of accelerated measles control activities
    (increased routine immunization coverage and mass immunization
    campaigns) at a donor cost of $184/death averted, making measles
    mortality reduction one of the most cost-effective public health
    interventions.
        Nearly all the measles vaccination campaigns have been able to
    reach more than 90 percent of their target populations. Countries
    recognize the opportunities that measles vaccination campaigns provide
    in accessing mothers and young children, and ``integrating'' the
    campaigns with other life-saving health interventions has become the
    norm. In addition to measles vaccine, Vitamin A (crucial for preventing
    blindness in under nourished children), de-worming medicine, and
    insecticide-treated bed nets (ITNs) for malaria prevention are
    distributed during vaccination campaigns. The scale of these
    distributions is immense. For example, more than 37 million ITNs were
    distributed in vaccination campaigns in the last few years. The
    delivery of multiple child health interventions during a single
    campaign is far less expensive than delivering the interventions
    separately, and this strategy increases the potential positive impact
    on children's health from a single campaign.
        Countries are well positioned to achieve the 2010 goal and to take
    a bold step toward achievement of the 2015 Millennium Development Goal
    #4 of reducing under 5 child mortality. However, achieving the 2010
    goal will require:
      --Accelerating activities, both campaigns and further efforts to
            improve routine measles coverage, in India since it is the
            greatest contributor to the global burden of measles.
      --Sustaining the gains in reduced measles deaths, especially in
            Africa, by strengthening immunization programs to ensure that
            more than 90 percent of infants are vaccinated against measles
            through routine health services before their first birthday as
            well as conducting timely, high-quality follow-up campaigns.
      --Securing sufficient funding for measles-control activities both
            globally and nationally. The Measles Initiative faces a funding
            shortfall of an estimated $100 million for 2010. Implementation
            of timely follow-up campaigns is increasingly dependent upon
            countries funding these activities locally. The decrease in
            donor funds available at global level to support activities to
            reduce measles mortality makes increased political commitment
            and country ownership of the activities critical for achieving
            and sustaining the goal of reducing measles mortality by 90
            percent.
        If these challenges are not addressed, the remarkable gains made
    since 2000 will be lost and a major resurgence in measles deaths will
    occur.
        By controlling measles cases in other countries, U.S. children are
    also being protected from the disease. Measles can cause severe
    complications and death. A major resurgence of measles occurred in the
    United States between 1989 and 1991, with more than 55,000 cases
    reported. This resurgence was particularly severe, accounting for more
    than 11,000 hospitalizations and 123 deaths. Since then, measles
    control measures in the United States have been strengthened and
    endemic transmission of measles cases have been eliminated here since
    2000. However, importations of measles cases into this country continue
    to occur each year. In 2008, the number of reported measles cases in
    the United States more than doubled and outbreaks are currently on-
    going in Virginia, Maryland, Washington, District of Columbia,
    Pennsylvania, California, and Missouri. These outbreaks cause needless
    suffering and accrue public health costs which in the United States are
    upwards of $150,000 to respond to each case.
             the role of cdc in global measles mortality reduction
        Since fiscal year 2001, Congress has provided approximately $42
    million annually in funding to CDC for global measles control
    activities. These funds were used toward the purchase of approximately
    415 million doses of measles vaccine for use in large-scale measles
    vaccination campaigns in more than 60 countries in Africa and Asia, and
    for the provision of technical support to Ministries of Health in those
    countries. Specifically, this technical support includes:
      --Planning, monitoring, and evaluating large-scale measles
            vaccination campaigns;
      --Conducting epidemiological investigations and laboratory
            surveillance of measles outbreaks; and
      --Conducting operations research to guide cost-effective and high-
            quality measles control programs.
        In addition, CDC epidemiologists and public health specialists have
    worked closely with the WHO, UNICEF, the United Nations Foundation, and
    the American Red Cross to strengthen measles control programs at global
    and regional levels.
        While it is not possible to precisely quantify the impact of CDC's
    financial and technical support to the Measles Initiative, there is no
    doubt that CDC's support--made possible by the funding appropriated by
    Congress--was essential in helping achieve the sharp reduction in
    measles deaths in just 7 years.
        The American Red Cross and the United Nations Foundation would like
    to acknowledge the leadership and work provided by CDC and recognize
    that CDC brings much more to the table than just financial resources.
    The Measles Initiative is fortunate in having a partner that provides
    critical personnel and technical support for vaccination campaigns and
    in response to disease outbreaks. CDC personnel have routinely
    demonstrated their ability to work well with other organizations and
    provide solutions to complex problems that help critical work get done
    faster and more efficiently.
        In fiscal year 2009, Congress has appropriated approximately $41.8
    million to fund CDC for global measles control activities. The American
    Red Cross and the United Nations Foundation thank Congress for the
    financial support that has been provided to CDC in the past and this
    year. We respectfully request a total of $51.8 million for fiscal year
    2010 funding for CDC's measles control activities so that the gains
    made to date can continue and the 2010 goal of a 90 percent reduction
    in measles deaths can be achieved.
        The additional funds we are seeking for CDC are critical for:
      --Sustaining the great progress in measles mortality reduction in
            Africa by strengthening measles surveillance and strengthening
            the delivery of measles vaccine through routine immunization
            services to protect new birth cohorts;
      --Conducting large-scale measles vaccination campaigns in South Asia,
            especially in India, thus protecting millions of children;
        Your commitment has brought us unprecedented victories in reducing
    measles mortality around the world. In addition, your continued support
    for this initiative helps prevent children from suffering from this
    preventable disease both abroad and in the United States.
        Thank you for the opportunity to submit testimony.
                                     ______

       Prepared Statement of the Americans for Nursing Shortage Alliance
        The undersigned organizations of the ANSR Alliance greatly
    appreciate the opportunity to submit written testimony on fiscal year
    2010 appropriations for Title VIII--Nursing Workforce Development
    Programs. The Alliance represents a diverse cross-section of health
    care and other related organizations, healthcare providers, and
    supporters of nursing issues that have united to address the national
    nursing shortage. We stand ready to work with the 111th Congress to
    advance programs and policies that will ensure that our Nation has a
    sufficient and adequately prepared nursing workforce to provide quality
    care to all well into the 21st century. The Alliance, therefore, urges
    Congress to:
      --Appropriate $263.4 million in funding in fiscal year 2010 for the
            Nursing Workforce Development Programs under title VIII of the
            Public Health Service Act at the Health Resources and Services
            Administration (HRSA).
      --Fund the Advanced Education Nursing program (section 811) at an
            increased level on par with the other title VIII programs.
                       the extent of the nursing shortage
        Nursing is the largest healthcare profession in the United States.
    According to the National Council of State Boards of Nursing, there
    were nearly 3.4 million licensed registered nurses (RNs) in 2006.\1\
    Nurses and advanced practice nurses (nurse practitioners, nurse
    midwives, clinical nurse specialists, and certified registered nurse
    anesthetists) work in a variety of settings, including primary care,
    public health, long-term care, surgical care facilities, and hospitals.
    Approximately 59 percent of RN jobs are in hospitals.\2\ A Federal
    report published in 2004 estimates that by 2020 the national nurse
    shortage will increase to more than 1 million full-time nurse
    positions. According to these projections, which are based on the
    current rate of nurses entering the profession, only 64 percent of
    projected demand will be met.\3\ A study, published in March 2008, uses
    different assumptions to calculate an adjusted projected demand of
    500,000 full-time equivalent registered nurses by 2025.\4\ According to
    the U.S. Bureau of Labor Statistics, about 233,000 additional jobs for
    registered nurses will open each year through 2016, in addition to
    about 2.5 million existing positions. Based on these scenarios, the
    shortage presents an extremely serious challenge in the delivery of
    high-quality, cost-effective services, as the Nation looks to reform
    the current healthcare system. Even considering only the smaller
    projection of vacancies, this shortage still results in a critical gap
    in nursing service, essentially three times the 2001 nursing shortage.
    ---------------------------------------------------------------------------
        \1\ National Council of State Boards of Nursing. (2008). 2006 Nurse
    Licensee Volume and NCLEX Examination Statistics. (Research Brief Vol.
    31). On the Internet at: https://www.ncsbn.org/
    08_2006_LicExamRB_Vol31_21208_MW(1).pdf. (Accessed February 3, 2009).
        \2\ Bureau of Labor Statistics, U.S. Department of Labor.
    Occupational Outlook Handbook, 2008-2009 Edition, Registered Nurses. On
    the Internet at: http://www.bls.gov/oco/ocos083.htm (Accessed December
    9, 2008).
        \3\ Health Resources and Services Administration, (2004) What is
    Behind HRSA's Projected Supply, Demand, and Shortage of Registered
    Nurses? On the Internet at: http://bhpr.hrsa.gov/healthworkforce/
    reports/behindrnprojections/4.htm. (Accessed December 9, 2008).
        \4\ Buerhaus, P., Staiger, D., Auerbach, D. (2008). The Future of
    the Nursing Workforce in the United States: Data, Trends, and
    Implications. Boston, MA: Jones & Bartlett.
    ---------------------------------------------------------------------------
              building the capacity of nursing education programs
        Nursing vacancies exist throughout the entire healthcare system,
    including long-term care, home care, and public health. Even the
    Department of Veterans Affairs, the largest sole employer of RNs in the
    United States, has a nursing vacancy rate of 10 percent. In 2006, the
    American Hospital Association reported that hospitals needed 116,000
    more RNs to fill immediate vacancies, and that this 8.1 percent vacancy
    rate affects hospitals' ability to provide patient/client care.\5\
    Government estimates indicate that this situation only promises to
    worsen due to an insufficient supply of individuals matriculating in
    nursing schools, an aging existing workforce, and the inadequate
    availability of nursing faculty to educate and train the next
    generation of nurses. At the exact same time that the nursing shortage
    is expected to worsen, the baby boom generation is aging and the number
    of individuals with serious, life-threatening, and chronic conditions
    requiring nursing care will increase. Consequently, more must be done
    today by the Government to help ensure an adequate nursing workforce
    for the patients/clients of today and tomorrow.
    ---------------------------------------------------------------------------
        \5\ American Hospital Association, (2007) The State of America's
    Hospitals: Taking the Pulse, Findings from the 2007 AHA Survey of
    Hospital Leader. On the Internet at: http://www.aha.org/aha/content/
    2007/PowerPoint/StateofHospitalsChartPack2007.ppt. (Accessed December
    3, 2008).
    ---------------------------------------------------------------------------
        A particular focus on securing and retaining adequate numbers of
    faculty is essential to ensure that all individuals interested in--and
    qualified for--nursing school can matriculate in the year they are
    accepted. In the 2006-2007 academic years, 99,000 qualified
    applications--or almost 40 percent of qualified applications submitted
    to prelicensure RN programs--were denied due to lack of capacity.\6\
    Aside from having a limited number of faculty, nursing programs
    struggle to provide space for clinical laboratories and to secure a
    sufficient number of clinical training sites at healthcare facilities.
    ---------------------------------------------------------------------------
        \6\ National League for Nursing, (2009) Nursing Data Review 2006-
    2007: Baccalaureate, Associate Degree, and Diploma Programs. On the
    Internet at: http://www.nln.org/research/slides/index.htm. (Accessed
    March 20, 2009).
    ---------------------------------------------------------------------------
        ANSR supports the need for sustained attention on the efficacy and
    performance of existing and proposed programs to improve nursing
    practices and strengthen the nursing workforce. The support of research
    and evaluation studies that test models of nursing practice and
    workforce development is integral to advancing healthcare for all in
    America. Investments in research and evaluation studies have a direct
    effect on the caliber of nursing care. Our collective goal of improving
    the quality of patient/client care, reducing costs, and efficiently
    delivering appropriate healthcare to those in need is served best by
    aggressive nursing research and performance and impact evaluation at
    the program level.
            the impact on the nation's public health infrastructure
        The National Center for Health Workforce Analysis reports that the
    nursing shortage challenges the healthcare sector to meet current
    service needs. Nurses make a difference in the lives of patients/
    clients from disease prevention and management to education to
    responding to emergencies. Chronic diseases, such as heart disease,
    stroke, cancer, and diabetes, are the most preventable of all health
    problems as well as the most costly. Nearly half of Americans suffer
    from one or more chronic conditions and chronic disease accounts for 70
    percent of all deaths. In addition, increased rates of obesity and
    chronic disease are the primary cause of disability and diminished
    quality of life.
        Even though America spends more than $2 trillion annually on
    healthcare--more than any other Nation in the world--tens of millions
    of Americans suffer every day from preventable diseases such as type 2
    diabetes, heart disease, and some forms of cancer that rob them of
    their health and quality of life.\7\ In addition, major vulnerabilities
    remain in our emergency preparedness to respond to natural,
    technological and manmade hazards. An October 2008 report issued by
    Trust for America's Health entitled ``Blueprint for a Healthier
    America'' found that the health and safety of Americans depends on the
    next generation of professionals in public health.\8\ Further, existing
    efforts to recruit and retain the public health workforce are
    insufficient. New policies and incentives must be created to make
    public service careers in public health an attractive professional
    path, especially for the emerging workforce and those changing careers.
    ---------------------------------------------------------------------------
        \7\ KaiserEDU.org. ``U.S. Health Care Costs: Background Brief.''
    Kaiser Family Foundation. On the Internet at: http://www.kaiseredu.org/
    topics_im.asp?imID=1&parentID=61&id=358 (Accessed November 24, 2008).
        \8\ Trust for America's Health. (2008) Blueprint for a Healthier
    America: Modernizing the Federal Public Health System to Focus on
    Prevention and Preparedness. On the Internet at: http://
    healthyamericans.org/report/55/blueprint-for-healthier-america
    (Accessed December 3, 2008).
    ---------------------------------------------------------------------------
        An Institute of Medicine report notes that nursing shortages in
    U.S. hospitals continue to disrupt hospitals operations and are
    detrimental to patient/client care and safety.\9\ Hospitals and other
    healthcare facilities across the country are vulnerable to mass
    casualty incidents themselves and/or in emergency and disaster
    preparedness situations. As in the public health sector, a mass
    casualty incident occurs as a result of an event where sudden and high-
    patient/client volume exceeds the facilities/sites resources. Such
    events may include the more commonly realized multi-car pile-ups, train
    crashes, hazardous material exposure in a building or within a
    community, high-occupancy catastrophic fires, or the extraordinary
    events such as pandemics, weather-related disasters, and intentional
    catastrophic acts of violence.
    ---------------------------------------------------------------------------
        \9\ Institute of Medicine, Committee on the Future of Emergency
    Care in the United States Health System. (2007) Hospital-Based
    Emergency Care: At the Breaking Point. On the Internet at: http://
    www.iom.edu/?id=48896. (Accessed December 3, 2008).
    ---------------------------------------------------------------------------
        Since 80 percent of disaster victims present at the emergency
    department, nurses as first receivers are an important aspect of the
    public health system as well as the healthcare system in general. The
    nursing shortage has a significant adverse impact on the ability of
    communities to respond to health emergencies, including natural,
    technological and manmade hazards.
                                    summary
        The link between healthcare and our Nation's economic security and
    global competitiveness is undeniable. Having a sufficient nursing
    workforce to meet the demands of a highly diverse and aging population
    is an essential component to reforming the healthcare system as well as
    improving the health status of the Nation and reducing healthcare
    costs. To mitigate the immediate effect of the nursing shortage and to
    address all of these policy areas, ANSR requests $263.4 million in
    funding for the Nursing Workforce Development Programs under title VIII
    of the Public Health Service Act at HRSA in fiscal year 2010. As part
    of this funding, the Advanced Education Nursing training program
    (section 811) should be funded at an increased level on par with the
    other title VIII programs.
                           undersigned organizations
        Academy of Medical-Surgical Nurses; American Academy of Ambulatory
    Care Nursing; American Academy of Nurse Practitioners; American Academy
    of Nursing; American Association of Critical-Care Nurses; American
    Association of Nurse Anesthetists; American Association of Nurse
    Assessment Coordinators; American Association of Nurse Executives;
    American Association of Occupational Health Nurses; American College of
    Nurse Practitioners.
        American Organization of Nurse Executives; American Psychiatric
    Nurses Association; American Society for Pain Management Nursing;
    American Society of PeriAnesthesia Nurses; American Society of Plastic
    Surgical Nurses; Association for Radiologic & Imaging Nursing;
    Association of Pediatric Hematology/Oncology Nurses; Association of
    periOperative Registered Nurses; Association of Rehabilitation Nurses;
    Association of State and Territorial Directors of Nursing.
        Association of Women's Health, Obstetric & Neonatal Nurses;
    Developmental Disabilities Nurses Association; Emergency Nurses
    Association; Gerontological Advanced Practice Nurses Association;
    Infusion Nurses Society; International Society of Nurses in Genetics,
    Inc.; Legislative Coalition of Virginia Nurses; National Association of
    Clinical Nurse Specialists; National Association of Neonatal Nurses;
    National Association of Neonatal Nurse Practitioners.
        National Association of Nurse Massage Therapists; National
    Association of Nurse Practitioners in Women's Health; National
    Association of Orthopaedic Nurses; National Association of Pediatric
    Nurse Practitioners; National Association of Registered Nurse First
    Assistants; National Black Nurses Association; National Council of
    State Boards of Nursing; National Gerontological Nursing Association;
    National League for Nursing; National Nursing Centers Consortium.
        National Nursing Staff Development Organization; National
    Organization for Associate Degree Nursing; National Organization of
    Nurse Practitioner Faculties; National Student Nurses' Association,
    Inc.; Nurses Organization of Veterans Affairs; Oncology Nursing
    Society; Pediatric Endocrinology Nursing Society; RN First Assistants
    Policy & Advocacy Coalition; Society of Gastroenterology Nurses and
    Associates, Inc.; Society of Pediatric Nurses; Society of Trauma
    Nurses; Wound, Ostomy and Continence Nurses Society.
                                     ______

        Prepared Statement of the Americans for Nursing Shortage Relief
                                    Alliance
        The Tri-Council for Nursing, a long-standing alliance focused on
    leadership and excellence in the nursing profession, is composed of the
    American Association of Colleges of Nursing, the American Nurses
    Association, the American Organization of Nurse Executives, and the
    National League for Nursing. The collaborative leadership of these four
    professional organizations impacts the breadth of nursing practice,
    including nurse executives, educators, researchers, and nurses
    providing direct patient care. The Tri-Council asks the subcommittee to
    provide $215 million in fiscal year 2010 for the Nursing Workforce
    Development Programs under title VIII of the Public Health Service Act,
    administered by the Health Resources and Services Administration
    (HRSA).
        In light of the economic challenges facing our country today, the
    Tri-Council urges the subcommittee to focus on the larger context of
    building the capacity needed to meet the increasing health care demands
    of our Nation's population. Such public policy will require sustained
    investments aimed at refocusing the current health care system toward
    promoting health, while simultaneously improving value for our dollars.
    The title VIII Nursing Workforce Development Programs are proven policy
    instruments that help assure an adequately prepared nursing workforce.
    These programs--
      --Increase access to healthcare in underserved areas through improved
            composition, diversity, and retention of the nursing workforce;
      --Advance quality care by strengthening nursing education and
            practice; and
      --Develop the identification and use of data, program performance
            measures, and outcomes to make informed decisions on nursing
            workforce matters.
        The Tri-Council applauds the subcommittee for the emergency
    supplement provided across all the health professions programs via the
    American Recovery and Reinvestment Act (Public Law 111-5). We also
    value the enacted fiscal year 2009 omnibus appropriations bill (Public
    Law 111-8) providing $171.031 million specifically for the title VIII
    Nursing Workforce Development Programs. These investments are a
    critical component supporting our healthcare infrastructure.
        Examining the broad context, the healthcare industry remains the
    largest industrial complex in the United States. Studies of the
    Nation's gross domestic product (GDP) show healthcare spending
    achieving a relatively high rate of real growth, with the portion of
    GDP devoted to healthcare growing from 8.8 percent in 1980 to 16.2
    percent of GDP in 2007. While healthcare spending demands greater
    efficiencies, it also has helped to sustain our Nation's sagging
    economy.
        Since 2001, healthcare is virtually the only sector that added jobs
    to the economy on a net basis. In March 2009, the U.S. Bureau of Labor
    Statistics (BLS) reported continued growth in the healthcare sector,
    despite our economy's freefall in a down cycle with unemployment
    reaching 8.1 percent in February 2009. With that month's job loss of
    681,000 realized in nearly all major industries, BLS also reported the
    addition of 27,000 new jobs at hospitals, long-term care facilities,
    and other ambulatory care settings.
        As the predominant occupation in the healthcare industry, the nurse
    workforce likely is filling most of the noted job openings. Nurses are
    the front line of healthcare delivery throughout the Nation, and the
    BLS numbers support that description showing the nurse workforce at
    well over four times the size of the medical workforce. Increased
    fiscal year 2010 investments in title VIII will help counterbalance the
    economic meltdown threatening nursing programs operating in
    congressional districts and serving communities by supporting nursing
    education--providing title VIII loans, scholarships, traineeships, and
    programmatic funding.
                  nursing shortage outpaces capacity-building
        The Tri-Council contends that an episodic increased funding of
    title VIII will not fully fill the gap generated by an 11-year nursing
    shortage felt throughout the entire U.S. health system and projected to
    continue. The BLS projections estimate that RNs will have the greatest
    growth rate of all U.S. occupations in the period spanning 2006-2016,
    with more than 1 million new and replacement nurses needed by 2016.
    Despite this projected expansion in the profession, numerous other
    studies anticipate a growing national nurse workforce shortage to
    intensify as the baby boomer cohort ages, the current nurse workforce
    retires, and the demand for healthcare accrues.
        Funding levels for the HRSA Title VIII Nursing Workforce Programs
    are failing to support the numerous qualified applicants seeking
    assistance from these programs. In the last 3 years, virtually flat
    title VIII funding, along with inflation and increased educational and
    administrative costs, has decreased purchasing power. According to HRSA
    statistics, in fiscal year 2006 the title VIII programs directly or
    indirectly supported 91,189 nurses and nursing students. In fiscal year
    2007, the number of grantees dropped by 21 percent and in 2008 the
    grantees dropped by 28 percent to support only 51,657 nurses and
    nursing students.
        Additionally, schools of nursing continue to suffer from a growing
    shortage of faculty, a troubling infrastructure trend that exacerbates
    the nurse workforce demand-supply gap. According to a study conducted
    by the American Association of Colleges of Nursing (AACN) in 2008,
    schools of nursing turned away 49,948 qualified applicants to
    baccalaureate and graduate nursing programs. The top reasons cited for
    not accepting these potential students was a lack of qualified nurse
    faculty and resource constraints. Without faculty, nursing education
    programs are prevented from admitting many qualified students who are
    applying to their programs. (Data are Internet accessible at http://
    www.aacn.nche.edu/Media/NewsReleases/ 2009/workforcedata.html.)
        The AACN survey results are reinforced by the National League for
    Nursing's (NLN) study of all types of prelicensure RN programs, which
    prepare students to sit for the RN licensing exam (i.e., baccalaureate,
    associate, and diploma degree). The NLN statistics indicate more than
    1,900 unfilled full-time faculty positions existed nationwide in 2007,
    affecting more than one-third (36 percent) of all schools of nursing.
    Significant recruitment challenges were found with 84 percent of
    nursing schools attempting to hire new faculty in 2007-2008, more than
    three-quarters (79 percent) reporting recruitment as ``difficult'' and
    almost 1 in 3 schools found it ``very difficult.'' The two main
    difficulties cited were ``not enough qualified candidates'' (cited by
    46 percent of schools), followed by inability to offer competitive
    salaries--cited by 38 percent. (Data are Internet accessible at
    www.nln.org/research/slides/index.htm.)
                              the funding reality
        If the United States is to reverse the eroding trends in the nurse
    and nurse faculty workforce, the Nation must make a significant
    investment in the title VIII programs, which are charged to favor
    institutions educating nurses for practice in rural and medically
    underserved communities. At adequate funding levels the title VIII
    programs supporting the education of registered nurses, advanced
    practice registered nurses, nurse faculty, and nurse researchers have
    demonstrated successful intervention strategies to solving past nursing
    shortages.
        A brief examination of the HRSA title VIII illustrates the robust
    nature of these programs:
        Section 811.--The Advanced Education Nursing (AEN) Program funds
    traineeships for individuals preparing to be nurse practitioners, nurse
    midwives, nurse administrators, public health nurses, and nurse
    educators, among other graduate-level education nursing roles. The AEN
    awards assisted nurse education programs to support 3,419 graduate
    nursing students in fiscal year 2008.
        Section 821.--The Nursing Workforce Diversity Program funds grants
    and contracts to schools of nursing, nurse-managed health centers
    (NMCs), academic health centers, State and local governments, and
    nonprofit entities to increase nursing education opportunities for
    individuals from disadvantaged backgrounds and under-represented
    populations among RNs. This program--of proven intervention
    strategies--supported 18,741 students in fiscal year 2008, seeking to
    ensure a culturally diverse workforce to provide healthcare for a
    culturally diverse patient population.
        Section 831.--The Nurse Education, Practice and Retention Program
    provides support for academic and continuing education projects
    designed to strengthen the nursing workforce. Several of this program's
    priorities apply to quality patient care including developing cultural
    competencies among nurses and providing direct support to establishing
    or expanding NMCs in noninstitutional settings to improve access to
    primary healthcare in medically underserved communities. The program
    also provides grants to improve retention of nurses and enhanced
    patient care. In fiscal year 2008, approximately 6,000 nurses and
    nursing students were supported.
        Section 846.--The Nurse Loan Repayment and Scholarship Programs
    (NELRP) is divided into two primary elements. The NELRP assists
    individual RNs by repaying up to 85 percent of their qualified
    educational loans over 3 years in return for their commitment to work
    at health facilities with a critical shortage of nurses, such as
    departments of public health, community health centers, and
    disproportionate share hospitals. In fiscal year 2008, of the 5,875
    applications reviewed by HRSA, only 435 students (7.4 percent) received
    NELRP awards. Similarly, the Nurse Scholarship Program (NSP) provides
    financial aid to individual nursing students in return for working a
    minimum of 2 years in a healthcare facility with a critical nursing
    shortage. In fiscal year 2008, NSP turned away most of the applicants
    owing to a lack of adequate funding, resulting in the distribution of
    only 169 student awards.
        Section 846A.--The Nurse Faculty Loan Program (NFLP) supports the
    establishment and operation of a loan fund within participating schools
    of nursing to assist RNs to complete their education to become nursing
    faculty. The NFLP grants provide a cancellation provision in which 85
    percent of the loan, plus interest, may be cancelled over 4 years in
    return for serving as full-time faculty in a school of nursing. NFLP
    granted 729 awards in fiscal year 2008.
        Section 855.--The Comprehensive Geriatric Education Grant Program
    focuses on training, curriculum development, faculty development, and
    continuing education for nursing personnel caring for the elderly. In
    fiscal year 2008, 18 awards were made in this program.
        While title VIII is the largest source of Federal funding for
    nursing, the current level of investment falls short of remedying a
    chronic underfunding of the Nursing Workforce Development Programs,
    compared to the existing and imminent shortages these programs address.
    The title VIII authorities are capable of providing flexible and
    effective support to assist students, schools of nursing, and health
    systems in their efforts to recruit, educate, and retain registered
    nurses. Recent efforts have shown that aggressive and innovative
    strategies can help avert the nurse and nurse faculty shortages. The
    Tri-Council for Nursing understands the competing priorities faced by
    this Congress, but we also maintain that title VIII Nursing Workforce
    Development Programs must be funded at an adequate level to begin to
    impact the shortage and to address the complex health needs of the
    Nation. The contributions of nurses in our healthcare system are
    multifaceted, and are impacted directly by the level of Federal funding
    that supports nursing programs.
                                     ______

                Prepared Statement of America's Promise Alliance
               the dropout crisis: america's new silent epidemic
        Chairman Inouye, Vice Chairman Cochran, members of the
    subcommittee, thank you for the opportunity to testify on the most
    pressing issue facing our Nation: the high school dropout crisis.
    America's low graduation rate is our most pressing issue as a Nation
    and the culmination of years of failure. Everyone with a stake in the
    future of our children and the Nation--schools, parents, businesses,
    community, and faith-based organizations--have a role to play in the
    resolution of this crisis. We all must work together in new and
    unprecedented ways in support of our children.
        In addition to its significant social implications, the potential
    economic impact of the dropout crisis shows why this issue is our most
    critical national challenge. Today, America is the only industrialized
    nation in the world where children are less likely to graduate from
    high school than their parents. A student drops out of high school
    every 26 seconds, with 1.2 million kids falling through the cracks each
    year. The national dropout crisis has resulted in 3 in 10 students
    failing to graduate with their class, a percentage that doubles for
    minority, urban, and low-income students.
        When President Obama and Secretary Duncan say that a long-term,
    sustainable economic recovery is only possible if we strengthen our
    education system, they are precisely correct. The dropout crisis may
    not be as visible or swift as other important issues problems facing
    this Congress and our new administration, but its implications are just
    as severe and lasting. The dropout crisis, persisting without
    acknowledgment or resolution, has emerged as America's ``silent
    epidemic.'' Although we are working diligently to raise public
    awareness of this issue, it has yet to permeate the national agenda.
    This makes it easier for our actions to be slow, inadequate, or even
    worse, nonexistent.
        Strengthening our graduation rate will take historic focus,
    unprecedented collaboration, and significant resources. The required
    investments in our young people are the most cost-effective investments
    we can make. We must understand that our future is at stake, and we
    must resolve that failure is not an option.
                        magnitude of the dropout crisis
        Between 25 to 30 percent of high school students do not graduate on
    time. For young people of color, on-time graduation is a 50-50
    proposition, the flip of a coin. A new report commissioned by America's
    Promise Alliance and developed by the Editorial Projects in Education
    Research Center found that only 53 percent of all young people in the
    Nation's 50 largest cities graduate on time. Despite some progress made
    by several of these cities between 1995 and 2005, the average
    graduation rate of the 50 largest cities is well below the national
    average of 71 percent, and an 18 percentage point urban-suburban gap
    remains.\1\ While the Nation's 50 largest school districts educate 1
    out of 8 high school students; they produce one-quarter of the Nation's
    students who do not graduate on time.\2\
    ---------------------------------------------------------------------------
        \1\ Christopher Swanson (2009). Cities in Crisis 2009: Closing the
    Graduation Gap: Educational and Economic Conditions in America's
    Largest Cities. Bethesda, Maryland: Editorial Projects in Education
    Research Center.
        \2\ The principal school districts of America's 50 largest cities
    collectively educate 1.7 million public high school students and
    produce 279,000 of the 1.2 million high school students who do not
    graduate on time (Ibid., p. 13).
    ---------------------------------------------------------------------------
        A significant graduation rate gap exists between urban and suburban
    school districts: 18 percentage points separate the metropolitan areas
    of the 50 largest cities from their suburban counterparts.\3\ Fifty-
    nine percent of high school students in urban school districts graduate
    on time from high school versus 77 percent of their suburban
    counterparts. The urban-suburban gap is most prominent in the Northeast
    and Midwest, with Baltimore, Cleveland, Columbus, and Milwaukee
    experiencing the largest differentials.\4\
    ---------------------------------------------------------------------------
        \3\ Ibid.
        \4\ Ibid.
    ---------------------------------------------------------------------------
    Economic Impact
        The economic significance of the Nation's low graduation rate
    cannot be overstated, as countries that out-educate us today will out-
    compete us tomorrow. A report from McKinsey & Company estimated the
    economic impact in 2008 if the United States had closed the achievement
    gap 15 years after A Nation at Risk's 1983 release. Their findings
    amount to nothing less than a multibillion dollar lost opportunity and
    what they term as a ``permanent national recession.'' Closing the
    international achievement, racial, and income gaps would have produced
    up to a 30 percent gain in GDP, or $4.2 trillion.
        On an individual level, high school graduation is a determining
    factor of a student's future income. High school dropouts are less
    likely to be steadily employed and earn less income when they are
    employed compared with those who graduate from high school. Only 37
    percent of high school dropouts nationwide are steadily employed and
    are more than twice as likely to live in poverty.\5\
    ---------------------------------------------------------------------------
        \5\ Ibid.
    ---------------------------------------------------------------------------
        High school dropouts account for 13 percent of the adult
    population, but earn less than 6 percent of all dollars earned in the
    United States. In the 50 largest cities, the median income for high
    school dropouts is $14,000, lower than the median income of $24,000 for
    high school graduates and $48,000 for college graduates. The Editorial
    Projects in Education Research Center estimates that earning a high
    school diploma would increase one's annual income by an average of 71
    percent, or $10,000.\6\
    ---------------------------------------------------------------------------
        \6\ Ibid.
    ---------------------------------------------------------------------------
                           contributors to the crisis
        There are two major influences in students' lives that impact their
    scholastic achievement: what happens inside the school building and
    what happens outside of it. A number of factors contribute to the high
    school dropout crisis, ranging from the quality of standards and rigor
    in our high schools to the issues impacting students before they ever
    step foot into the classroom.
        In 1983, A Nation at Risk recommended that schools, colleges, and
    universities adopt more rigorous, measurable standards for academic
    performance and higher expectations for student conduct. Today, few
    disagree with the need to raise expectations of student performance. We
    must offer our students challenging curricula that are aligned with the
    expectations of college and the needs of our future workforce. We need
    stronger, internationally benchmarked standards, so that students,
    educators, and parents understand the effectiveness of the educational
    system in which they are part.
        Equally important, though not duly recognized, is the importance of
    a student's living and learning environment in affecting how he or she
    performs in the classroom. Schools cannot shoulder the responsibility
    of educating our children and youth on their own. Every year, our
    students spend about 1,150 waking hours in school, and nearly five
    times that number (4,700 waking hours) in their families and
    communities.\7\ Today's teachers have to act as mothers, fathers,
    social workers, and sometimes even police officers, in addition to the
    central task of educating our students.
    ---------------------------------------------------------------------------
        \7\ David Berliner (2009). Poverty and Potential: Out-of-School
    Factors and School Success. Boulder and Tempe: Education and the Public
    Interest Center and Education Policy Research Unit. Retrieved May 6,
    2009 from http://epicpolicy.org/publication/poverty-and-potential.
    ---------------------------------------------------------------------------
        In its recent report, Parsing the Achievement Gap II, the
    Educational Testing Service (ETS) outlined 16 factors that correlate
    with student achievement; more than half of these factors are present
    in a child's life before or beyond the classroom, including forced
    mobility, hunger and nutrition, and summer achievement gain and
    loss.\8\ Today's educators must address the confluence of many of these
    factors at the same time, which are disproportionately concentrated in
    the Nation's poorest schools. Less than 4 percent of white students
    attend schools where 70-100 percent of the students are poor. However,
    40 percent of black and Latino students attend such high-poverty
    schools.
    ---------------------------------------------------------------------------
        \8\ Paul Barton and Richard Coley (2009). Parsing the Achievement
    Gap II. Princeton, New Jersey: Educational Testing Service. Note: This
    report uses the term ``frequent school changes.'' I use the term
    ``forced mobility'' because it more accurately describes the living
    circumstances of our most at-risk students that, in turn, causes
    reductions in school performance. For additional information, see
    Duffield and Lovell (endnote 20).
    ---------------------------------------------------------------------------
        It is important that we have a thorough understanding of the
    prevalence and importance of the larger environmental factors in a
    student's life that influence their academic success. Unless we address
    these foundational issues, not even the best teachers with the highest
    quality curriculum will be able to ensure that every student graduates
    ready for college.
                     the solution: a comprehensive approach
        The dropout crisis calls for a holistic solution, driven by
    national leadership and local action. Research demonstrates that young
    people need five core resources to be successful in life. We refer to
    them as the ``five promises:'' caring adults, safe places, a healthy
    start, effective education, and opportunities to serve. These promises
    provide a simple but powerful framework for a robust national strategy
    to end the dropout crisis, and they are at the heart of the Dropout
    Prevention Campaign launched by America's Promise Alliance in April
    2008.
    America's Promise Alliance Dropout Prevention Campaign
        The campaign begins with high-level summits in all 50 States and
    the 55 cities with the largest dropout rates in order to raise the
    visibility of America's ``silent epidemic.'' Within 60 days of each
    summit, States, and communities are required to develop action plans
    that include a cross section of stakeholders: educators, the business
    community, nonprofit organizations, and students. To date, 36 high-
    level summits have been held in cities nationwide--bringing together
    more than 14,000 mayors and Governors, business owners, child
    advocates, school administrators, students, and parents to develop
    workable solutions and action plans.
        Already, cities and States that held summits last year have started
    implementing changes based on the discussions and early results are
    promising. Detroit has set a 10-year goal to graduate 80 percent of its
    youth from the 35 high schools with significant dropout rates and
    created the Greater Detroit Venture Fund, a $10 million effort to
    assist these efforts. Louisville set a 10-year goal to cut dropout
    rates in half, and Tulsa's summit resulted in an innovative career
    exploration program.
    Grad Nation
        The Dropout Summits and the action plans they produce are a
    critical first step, but communities also need tools and guidelines for
    sustainably raising their graduation rates. Grad Nation is a first-of-
    its-kind research-based toolkit for communities seeking to reduce their
    dropout rate and better support young people through high school
    graduation and beyond. Commissioned by the Alliance and authored by
    Robert Balfanz, Ph.D. and Joanna Honig Fox from the Everyone Graduates
    Center at Johns Hopkins University and John M. Bridgeland and Mary
    McNaught of Civic Enterprises, Grad Nation brings together--in one
    place--the Nation's best evidence-based practices for keeping young
    people in school. Grad Nation gives communities a comprehensive set of
    tools to rally collective support, develop effective action strategies,
    prepare youth for advanced learning, and build strong, lasting
    partnerships around ending the dropout crisis.
    The Gallup Student Poll
        The youth voice is often overlooked and not included in the
    national dialogue on dropout prevention. In order to determine
    effective solutions to the crisis, their voices must be heard.
    America's Promise Alliance (APA), along with Gallup and the American
    Association of School Administrators, recently launched the Gallup
    Student Poll, the largest-ever survey of students in grades 5-12. The
    poll measures three key metrics--hope, engagement, and well-being--that
    research has shown have a meaningful impact on educational outcomes and
    more importantly, can be improved through deliberate action by
    educators, school administrators, community leaders.
        The March 2009 polling brought in nearly 71,000 responses from
    students in 18 States, 58 districts, and more than 330 schools. Half of
    those surveyed (50 percent) reported that they are not hopeful, with
    one-third (33 percent) indicating that they are stuck, while 17 percent
    feel discouraged. Just half (52 percent) said they were treated with
    respect all day. The findings from this and future Gallup Student Polls
    will highlight causes of the dropout crisis from the perspective of
    students themselves. The youth voice is a critical part of the ongoing
    dialogue about dropout prevention, and they can help us develop
    initiatives that sustainably change outcomes for our young people.
                             service and engagement
        The recently passed Edward M. Kennedy Serve America Act will boost
    the efforts of our Alliance's service initiatives through the most
    sweeping expansion of our country's service programs in 16 years. APA
    believes service is a bedrock strategy for tackling issues such as the
    high school dropout and college-readiness crises. By affirming the
    power of service to address some of the biggest challenges now facing
    the United States, this landmark piece of legislation will help reverse
    current dropout rates in communities across the country.
        The Serve America Act will update and strengthen national service
    programs, including service-learning, a teaching method that combines
    volunteer service and a rigorous curriculum to engage young people in
    solving community problems. Research has shown that service-learning
    helps students achieve academically, develop civic and career-related
    skills, increase their self-confidence, and heighten their respect for
    diversity. Service-learning is a key component of our objective to help
    communities in this time of need and to ensure brighter futures for our
    children and youth.
        Many students who ultimately drop out of school say they become
    disengaged during the middle-school years. The choices young people
    make at this age could set them on a course for active citizenship and
    engaged learning, or down a path of risky behavior and potential
    failure. Not enough opportunities currently exist for these children to
    engage in active learning through real-world experiences, such as
    school or community-based learning and career-centric activities.
        Our national action strategy, ``Ready for the Real World,'' brings
    together partners from professional societies and businesses looking
    for ways to connect with and prepare their future workforce. By
    designing ``real-world'' experiences relevant to them, the initiative
    exposes youth to service learning and career exploration, increasing
    their motivation to achieve in school, college, and life.
        Through America's Promise, partners provide a range of resources
    and real-life experiences, such as job shadowing and mentoring
    programs. Ready for the Real World established innovative after-school
    and summer programs for youth, which are integrated into school
    curriculums afterwards. This type experiential learning has inspired
    at-risk youth to achieve academically, pursue higher goals, and
    contribute positively to their communities.
                                     ______

          Prepared Statement of the American Psychological Association
        The American Psychological Association (APA), the largest
    scientific and professional organization representing psychology in the
    United States and the world's largest association of psychologists,
    works to advance psychology as a science, as a profession and as a
    means of promoting human welfare. APA is grateful for the opportunity
    to submit written testimony on goals for the fiscal year 2010
    appropriations bill. Below we enumerate recommendations for specific
    programs.
        Bureau of Health Professions, Graduate Psychology Education
    Program.--The APA requests that the subcommittee include $7 million for
    the Graduate Psychology Education Program (GPE) within the Health
    Resources and Services Administration. This nationally competitive
    grant program provides integrated healthcare services to underserved
    communities--those individuals most in need of mental and behavioral
    health support with the least access to these services, including
    children, older adults, chronically ill persons, and victims of abuse
    or trauma.
        Since 2002, GPE grants have provided interdisciplinary training for
    approximately 2,500 graduate students of psychology and other health
    professions to provide integrated healthcare services to underserved
    populations. There have been 70 grants in 30 States. Students
    benefiting from GPE grants have worked with more than 30 different
    types of health professionals. GPE funding has allowed programs to
    double the number of students they are able to train: and more students
    trained means more impact on underserved populations. The GPE Program
    currently supports training grants at 18 academic institutions and
    training sites (e.g., children's and VA hospitals) throughout the
    Nation. All of the approximately 900 psychology graduate students who
    benefited from GPE funds are expected to work with underserved
    populations and 34-100 percent will be working in underserved areas
    immediately after completing the training.
        Currently authorized under the Public Health Service Act (Public
    Law 105-392, section 755(b)(1)(J)) and funded under the ``Allied Health
    and Other Disciplines'' account in the Labor, Health and Human
    Services, and Education, and Related Agencies appropriations bill, this
    program has proven effective for meeting the growing health needs of
    our Nation's least served communities. This year, specific authorizing
    legislation has been introduced in the U.S. Senate (S. 811) as well as
    in the U.S. House of Representatives (H.R. 2066).
        The GPE program specifically seeks to support our Nation's aging
    and veteran populations. Twenty percent of people older than 55 suffer
    from a mental disorder (2005); mental disorders affect physical health
    and the ability to function (2008); and approximately 70 percent of all
    primary care visits by older adults are driven by psychological
    factors. In addition, older adults with chronic illnesses such as heart
    disease have higher rates of depression than those medically well, and
    depression lowers immunity and may compromise a person's ability to
    fight infection (2008). One in five military personnel returning from
    Iraq and Afghanistan report symptoms consistent with major depression,
    generalized anxiety or post-traumatic stress disorder (PTSD) (2008).
    According to the Pentagon the number of U.S. troops diagnosed by the
    military with PTSD jumped nearly 50 percent from 2006 to 2007 as more
    troops served lengthy and repeated tours in Iraq and Afghanistan
    (2008). Furthermore, the U.S. Army reported in May (2008) that more
    U.S. soldiers committed suicide in 2007 than at any time since the
    first Gulf War.
        Providing $7 million in fiscal year 2010 would allow for 30
    additional GPE grants including those that focus solely on the needs of
    older adults and returning military personnel and their families. There
    are approximately 900 eligible universities, professional schools and
    hospitals in every State nationwide.
       substance abuse and mental health services administration (samhsa)
    Garrett Lee Smith Memorial Act Programs--Campus Suicide Prevention
            Program
        APA encourages the subcommittee to increase funding for the
    programs at SAMHSA authorized by the Garrett Lee Smith Memorial Act,
    especially the Campus Suicide Prevention program.
        The Campus Suicide Prevention program is a small, but important
    program that seeks to assist college and universities raise awareness
    about mental and behavioral health to prevent suicides. By providing
    educational materials and outreach, the Campus Suicide Prevention
    program increases awareness about the signs of and risks of mental
    health problems and ensures greater success in college completion for
    those at risk of school failure because of concerns like stress,
    depression, eating disorders, risk behaviors, and suicidal thoughts.
        There is a special need to increase funds for this program during
    the difficult economic times facing our Nation. A recent APA survey
    found that 18-29 year olds felt the economy added to their stress more
    than other concerns, like relationships or housing, a change from past
    years. The American College Counseling Association's 2008 Survey of
    College Counseling Center Directors found that ``95 percent of
    directors report that the recent trend toward greater number of
    students with severe psychological problems continues to be true on
    their campuses.'' Addressing the mental and behavioral health needs of
    students in college and university settings can mean the difference
    between school failure or graduation on one hand, and life and death on
    the other.
        Center for Mental Health Services, Minority Fellowship Program
    (MFP).--While minorities are projected to comprise 40 percent of the
    U.S. population by 2025, only 23 percent of recent doctorates in
    psychology, social work, and nursing were awarded to minorities. The
    MFP's mission is to address this need by increasing the number of
    minority mental health professionals and by training mental health
    professionals to become culturally competent. APA urges Congress to
    fund the Minority Fellowship Program at $7.5 million for fiscal year
    2010.
        Emergency Mental Health and Traumatic Stress Services Branch: Child
    Trauma.--SAMHSA has made tremendous efforts in this area through the
    outstanding National Child Traumatic Stress Network program. APA urges
    Congress to appropriate full funding for the National Child Traumatic
    Stress Initiative at the originally authorized level of $50 million for
    fiscal year 2010. To ensure continuity of leadership in this program,
    APA recommends the subcommittee encourage SAMHSA to expand the duration
    of NCTSI grant awards from 3 years to 6 years.
        Center for Substance Abuse Prevention (CSAP): Substance Use and
    Mental Disorders of Persons with HIV.--According to recent reports,
    almost half of those with HIV/AIDS screened positive for illicit drug
    use or mental disorders. Unfortunately, healthcare providers fail to
    detect mental disorders and substance use problems in almost half of
    patients with HIV/AIDS. Several diagnostic screening tools are
    available for use by nonmental health staff. APA encourages SAMHSA and
    CDC to collaborate with HRSA to train healthcare providers to screen
    HIV/AIDS patients for mental health and substance use problems.
                    department of health and human services
        Lifespan Respite Program Family Caregivers.--Respite can provide
    family caregivers with relief necessary to maintain their own health,
    bolster family stability and well-being, and avoid or delay more costly
    nursing home or foster care placements. Under the Lifespan Respite Care
    Program, funds are available to improve access to respite for family
    caregivers. APA urges Congress to fund the Lifespan Respite Care
    Program at its authorized level of $71.1 million for fiscal year 2010.
                centers for disease control and prevention (cdc)
        National Center for Injury Prevention and Control: Child
    Maltreatment Prevention at Community Health Centers (CHCs).--APA
    recommends the implementation of at least 10 demonstration projects of
    evidence-based preventative parenting programs through CHCs. Technical
    assistance to demonstration sites should be provided by organizations
    with expertise in parent-child relationships, parenting programs,
    prevention of child maltreatment, and the integration of behavioral
    health in primary and community health center settings. APA recommends
    evaluating the demonstration projects' implementation and outcomes,
    including health and mental health outcomes.
        National Center for Health Statistics (NCHS): Eating Disorders.--
    Eating disorders may have serious, chronic effects on one's quality of
    life and often co-occur with significant physical and mental health
    problems. However, the impact of these disorders has not yet been
    appropriately investigated. APA urges the subcommittee to encourage CDC
    to increase support for surveillance and research efforts regarding the
    incidence, morbidity, and mortality rates of eating disorders,
    including anorexia nervosa, bulimia nervosa, binge eating disorder, and
    eating disorders not otherwise specified across age, ethnicity and
    gender subgroups.
        Sexual and Gender Identity Inclusion in Health Data Collection.--
    The National Health Interview Survey (NHIS) is the most comprehensive
    and widely referenced Federal health statistics survey, yet currently
    does not include any question concerning sexual orientation and gender
    identity. APA recommends the allocation of an additional $2 million in
    funding for NHIS in the NCHS budget, to enable Government agencies to
    better understand and plan for the unique health needs of lesbian, gay,
    bisexual, and transgender individuals.
        Administration for Children and Families.--Sexualization of Girls.
    Throughout U.S. culture, female children, adolescents, and adults are
    frequently depicted and treated in a sexualized manner that objectifies
    them. Research links sexualization with three of the most common mental
    health problems of female children, adolescents, and adults: eating
    disorders, depression or depressed mood, and low self-esteem. APA
    encourages HHS to fund media literacy and youth empowerment programs to
    prevent and counter the effects of the sexualization of female
    children, adolescents, and adults.
        National Institutes of Health (NIH).--APA supports the request of
    the Ad Hoc Group and Coalition for Health Funding, urging an increase
    of at least 7 percent for the NIH. Years of sub-inflation budgets have
    stressed the NIH research enterprise, and made sharing of resources
    among programs more difficult. The fiscal year 2009 increase provided
    by Congress begins to ameliorate the budget difficulties, but
    scientific research will benefit from a smooth, steady and predictable
    rise in spending.
        APA likewise supports an increase of 7 percent (to $28.61 million)
    for the NIH Office of Behavioral and Social Sciences Research in the
    Office of the Director. This small but important office coordinates
    behavioral and social science research initiatives across Institutes
    and Centers, and helps form partnerships to leverage the intellectual
    and monetary resources that make good science possible.
        The behavioral and social sciences are leading proponents of
    cooperation and cost-sharing in cross-cutting NIH initiatives. APA
    supports NIH's decision to authorize a Basic Behavioral and Social
    Sciences Research ``Blueprint,'' to which several Institutes would
    contribute, to strengthen NIH funding of basic research in the
    behavioral and social sciences. This innovation will build creative
    cooperation and cost-sharing, and help plug gaps in NIH-supported basic
    research.
        A key area of cooperation is in research on obesity. Given the role
    of obesity as a risk factor for the development of cardiovascular
    disease, diabetes, cancer, and arthritis, many of NIH's Institutes are
    collaborating with investigators and other Institutes to develop new
    ways to prevent and treat obesity and overweight as well as fostering
    the adoption of positive health behaviors.
        For example, the Eunice Kennedy Shriver National Institute of Child
    Health and Human Development supports research into physical activity
    and eating behaviors and that examines the impact of family and peer
    support, developmental and social context, school-based interventions,
    which include the use of media and literacy, motivation, and use of
    various behavioral approaches to influence motivation in physical
    activity, food choices, and media use.
        Alcohol and tobacco use are among the leading causes of death and
    disability in the United States, but NIH research funding to prevent,
    understand the etiology of, and treat tobacco and alcohol addiction is
    not commensurate with the public health burden of those diseases. APA
    suggests that as the NIH Scientific Management Review Board (SMRB)
    undertakes its review of the NIH organizational structure to optimize
    the research of substance use, abuse and addiction, that it also
    quantify the amount of NIH research funding dedicated to studies of
    alcohol, tobacco use and illicit substance use. Further, APA recommends
    that the SMRB evaluate the proportion of all substance use research
    funding at NIH compared to CDC estimates of the public health burden of
    disease (and costs to the criminal justice system) and consider a
    reapportionment of NIH funding to Institutes based on those findings.
                            department of education
        Office of the Director (OD).--Culturally and Linguistically
    Appropriate Education. Ethnically diverse children and American Indian/
    Alaska native children are performing at far lower levels than other
    students. APA urges the subcommittee to increase support for
    educational systems and the strengthening of programs that meet the
    unique cultural, linguistic and educational needs of ethnic minority
    and AI/AN students from pre-school to graduate-level education.
        Office of Safe and Drug-free Schools: Bullying Prevention.--
    Bullying directly affects about one-third of American school children
    in a given semester. APA urges appropriate Federal funding to support
    the implementation of effective, research-based, and comprehensive
    bullying prevention programs.
        National Institute on Disability and Rehabilitation Research:
    Disability Research.--APA recommends that NIDRR pursue mental health-
    related research proposals through its investigator-initiated and other
    grants programs, and sponsor studies on the impacts of socio-emotional,
    behavioral, and attitudinal aspects of disability.
               elementary and secondary school counseling program
        APA requests that the subcommittee increase funds for the
    Elementary and Secondary School Counseling program. Authorized by the
    Elementary and Secondary Education Act's Fund for the Improvement of
    Education, this program increases the range, availability, quantity,
    and quality of counseling services in the elementary and secondary
    schools across the country.
                                     ______

          Prepared Statement of the American Public Power Association
        The American Public Power Association (APPA) is the national
    service organization representing the interests of more than 2,000
    municipal and other State and locally owned utilities throughout the
    United States (all but Hawaii). Collectively, public power utilities
    deliver electricity to 1 of every 7 electricity consumers
    (approximately 45 million people), serving some of the Nation's largest
    cities. However, the vast majority of APPA's members serve communities
    with populations of 10,000 people or less.
        We appreciate the opportunity to submit this statement supporting
    funding for the Low-Income Home Energy Production Assistance Program
    (LIHEAP) for fiscal year 2010.
        APPA has consistently supported an increase in the authorization
    level for LIHEAP. The administration's fiscal year 2010 budget requests
    $3.2 billion for LIHEAP. APPA supports a level of $5.1 billion for the
    program.
        APPA is proud of the commitment that its members have made to their
    low-income customers. Many public power systems have low-income energy
    assistance programs based on community resources and needs. Our members
    realize the importance of having in place a well-designed, low-income
    customer assistance program combined with energy efficiency and
    weatherization programs in order to help consumers minimize their
    energy bills and lower their requirements for assistance. While highly
    successful, these local initiatives must be coupled with a strong
    LIHEAP program to meet the growing needs of low-income customers. In
    the last several years, volatile home-heating oil and natural gas
    prices, severe winters, high utility bills as a result of dysfunctional
    wholesale electricity markets and the effects of the economic downturn
    have all contributed to an increased reliance on LIHEAP funds.
        Also when considering LIHEAP appropriations this year, we encourage
    the subcommittee to provide advanced funding for the program so that
    shortfalls do not occur in the winter months during the transition from
    one fiscal year to another. LIHEAP is one of the outstanding examples
    of a State-operated program with minimal requirements imposed by the
    Federal Government. Advanced funding for LIHEAP is critical to enabling
    States to optimally administer the program.
        Thank you again for this opportunity to relay our support for
    increased LIHEAP funding for fiscal year 2010.
                                     ______

        Prepared Statement of the Association for Psychological Science
                           summary of recommendations
      --As a member of the Ad Hoc Group for Medical Research Funding,
            Association for Psychological Science (APS) recommends $32.4
            billion for the National Institutes of Health (NIH) in fiscal
            year 2010.
      --APS requests subcommittee support for behavioral and social science
            research and training as a core priority at NIH in order to:
            better meet the Nation's health needs, many of which are
            behavioral in nature; realize the exciting scientific
            opportunities in behavioral and social science research, and;
            accommodate the changing nature of science, in which new fields
            and new frontiers of inquiry are rapidly emerging.
      --Given the critical role of basic behavioral science research and
            training in addressing many of the Nation's most pressing
            public health needs, we ask the subcommittee to ensure that NIH
            leadership carries out its plan to create a cross-NIH basic
            behavioral research funding initiative, and coordinates with
            all Institutes and Centers to provide support for basic
            behavioral science research.
      --APS encourages the subcommittee to support behavioral science
            priorities at individual Institutes. Examples are provided in
            this testimony to illustrate the exciting and important
            behavioral and social science work being supported at NIH.
        Mr. Chairman, members of the subcommittee: My name is Dr. Amy
    Pollick, and I am speaking on behalf of the APS. Thank you for the
    opportunity to provide this statement on the fiscal year 2010
    appropriations for the NIH. As our organization's name indicates, APS
    is dedicated to all areas of scientific psychology, in research,
    application, teaching, and the improvement of human welfare. Our 21,000
    members are scientists and educators at the Nation's universities and
    colleges, conducting NIH-supported basic and applied, theoretical and
    clinical research. They look at such things as: the connections between
    emotion, stress, and biology and the impact of stress on health; they
    look at how children grow, learn, and develop; they use brain imaging
    to explore thinking and memory and other aspects of cognition; they
    develop ways to manage debilitating chronic conditions such as diabetes
    and arthritis as well as depression and other mental disorders; they
    look at how genes and the environment influence behavioral traits such
    as aggression and anxiety; and they address the behavioral aspects of
    smoking and drug and alcohol abuse.
        As a member of the Ad Hoc Group for Medical Research Funding, APS
    recommends $32.4 billion for NIH in fiscal year 2010, an increase of 7
    percent more than the fiscal year 2009 appropriations level. This
    increase would halt the erosion of the Nation's public health research
    enterprise, and help restore momentum to our efforts to improve the
    health and quality of life of all Americans.
        Within the NIH budget, APS is particularly focused on behavioral
    and social science research and the central role of behavior in health.
    The remainder of my testimony concerns the status of those areas of
    research at NIH.
          health and behavior: the critical role of basic and applied
                             psychological research
        Behavior is a central part of health. Many leading health
    conditions--such as heart disease; stroke; lung disease and certain
    cancers; obesity; AIDS; suicide; teen pregnancy; drug abuse and
    addiction; depression and other mental illnesses; neurological
    disorders; alcoholism; violence; injuries and accidents--originate in
    behavior and can be prevented or controlled through behavior.
        As just one example: stress is something we all feel in our daily
    lives, and we now have a growing body of research that illustrates the
    direct link between stress and health problems:
      --Chronic stress accelerates not only the size, but also the strength
            of cancer tumors;
      --chronic stressors weaken the immune system to the point where the
            heart is damaged, paving the way for cardiac disease;
      --children who are genetically vulnerable to anxiety and who are
            raised by stressed parents are more likely to experience
            greater levels of anxiety and stress later in life;
      --animal research has shown that stress interferes with working
            memory; and
      -- stressful interactions may contribute to systemic inflammation in
            older adults, which in turn extends negative emotion and pain
            over time.
        None of the conditions or diseases described above can be fully
    understood without an awareness of the behavioral and psychological
    factors involved in causing, treating, and preventing them. Just as
    there exists a layered understanding, from basic to applied, of how
    molecules affect brain cancer, there is a similar spectrum for
    behavioral research. For example, before you address how to change
    attitudes and behaviors around AIDS, you need to know how attitudes
    develop and change in the first place. Or, to design targeted therapies
    for bipolar disorder, you need to know how to understand how circadian
    rhythms work as disruptions in sleeping patterns have been shown to
    worsen symptoms in bipolar patients.
        basic behavioral science research needs a stable infrastructure
        Broadly defined, behavioral research explores and explains the
    psychological, physiological, and environmental mechanisms involved in
    functions such as memory, learning, emotion, language, perception,
    personality, motivation, social attachments, and attitudes. Within
    this, basic behavioral research aims to understand the fundamental
    nature of these processes in their own right, which provides the
    foundation for applied behavioral research that connects this knowledge
    to real-world concerns such as disease, health, and life stages. Basic
    behavioral research continues to fare poorly at NIH, a circumstance
    that jeopardizes the success of the entire behavioral research
    enterprise. Let me remind you of the current situation.
        Traditionally, the National Institute of Mental Health (NIMH) was
    the home for far more basic behavioral science than any other
    Institute. Many basic behavioral and social questions were being
    supported by NIMH, even if their answers could also be applied to other
    Institutes. But NIMH has reduced its support for many areas of the most
    basic behavioral research, in favor of translational and clinical
    research. This means that previously funded areas now are not being
    supported.
        NIMH's abrupt decision to narrow its portfolio came without
    adequate planning and happened at the expense of critical basic
    behavioral research. We favor a broader spectrum of support for basic
    behavioral science across NIH as appropriate and necessary for a vital
    research enterprise. But until other Institutes have the capacity to
    support more basic behavioral science connected to their missions,
    programs of research in fundamental behavioral phenomena such as
    cognition, emotion, psychopathology, perception, and development, will
    continue to languish.
        Current NIH leadership recognizes this gap, and has asked the
    Directors of the National Institute of General Medical Sciences and the
    National Institute of Aging to co-lead a new initiative that supports
    and expands new basic behavioral research throughout NIH. In March
    2009, NIH leadership confirmed its commitment to this Basic Behavioral
    Research Opportunity Network in testimony to this subcommittee, and APS
    asks you to ensure that NIH follows through with the planning and
    execution of this crucial step forward for basic behavioral science at
    NIH and ultimately the health of all Americans.
        Despite the clear central role of behavior in health, behavioral
    research has not received the recognition or support needed to prevent,
    or reverse the effects of, behavior-based health problems in this
    Nation. APS asks that you continue to help make behavioral research
    more of a priority at NIH, both by providing maximum funding for those
    Institutes where behavioral science is a core activity, by encouraging
    NIH to advance a model of health that includes behavior in its
    scientific priorities, and by encouraging stable support for basic
    behavioral science research at NIH.
                      behavioral science at key institutes
        In the remainder of my testimony, I would like to highlight
    examples of cutting-edge behavioral science research being supported by
    individual Institutes.
        National Cancer Institute (NCI).--NCI's Behavioral Research Program
    continues to make excellent progress, supporting basic behavioral
    research as well as translational research on the development and
    dissemination of interventions in areas such as tobacco use, dietary
    behavior, sun protection, and decisionmaking. Recently, NCI's
    behavioral research branch has made concerted efforts to incorporate
    innovative social psychological theories into cancer prevention
    research. Basic social psychology provides useful and practical
    approaches for understanding risky health behaviors and tailoring
    interventions to reduce the incidence of cancer. For example, NCI
    funded a research program to assess differential psychological and
    physiological responses to exercise and the possible genetic and
    biological mechanisms of those responses. As a result, we now
    understand the influence of responses to cardiovascular exercise on
    future exercise behavior, and the researchers are evaluating an
    intervention to increase exercise behavior in sedentary participants.
    It is this kind of basic behavioral research that helps us understand
    how people are persuaded to adopt and maintain healthy behaviors. APS
    asks Congress to support NCI's behavioral science research and training
    initiatives and to encourage other Institutes to use these programs as
    models.
        National Institute on Aging (NIA).--NIA's Division of Behavioral
    and Social Research has one of the strongest psychological science
    portfolios in all of NIH, and is supporting wide-ranging and innovative
    work. For example, normal aging may be accompanied by declines not only
    in such cognitive functions, but also in the processes supporting
    social and emotional behavior. However, we currently know little about
    the changes that may occur as we age. NIA-supported research into the
    brain mechanisms and cognitive processes underlying social and
    emotional behaviors in healthy older adults promises to dramatically
    increase our knowledge in this area. Using a combination of behavioral
    and neuroimaging methods to study social and emotional processing in
    normal aging, this research will lead to much greater understanding of
    the nature of aging-related changes in these central human
    characteristics. NIA's commitment to cutting-edge behavioral science is
    further illustrated by the Institute's leadership role in NIH's new
    initiative on the Science of Behavior Change. APS asks the subcommittee
    to support NIA's behavioral science research efforts and to increase
    NIA's budget in proportion to the overall increase at NIH in order to
    continue its high-quality research to improve the health and well being
    of older Americans.
        National Institute on Drug Abuse (NIDA).--By supporting a
    comprehensive research portfolio that stretches across behavior,
    neuroscience, and genetics, NIDA is leading the Nation to a better
    understanding of drug abuse which is key to both prevention and
    treatment. One of the striking things about psychological science
    research is that it often dispels ``common sense'' intuition. For
    example, recent NIDA-supported research has shown that certain anti-
    drug media campaigns that include attention-grabbing features such as
    harsh content or strong graphics, have no positive effect, and that in
    fact the campaigns that use fewer such dramatic features actually lead
    to better processing of the public service announcement (PSA). This
    kind of message-framing research will be used to develop and tailor the
    most effective PSAs, such as those that focus on social risk rather
    than physical damage, to curtail use of a wide variety of illicit
    substances. NIDA is also encouraging brain imaging and prevention
    message investigators to work together, fostering increased validation
    of health communication models. APS asks the subcommittee to support
    this and other critical behavioral science research at NIDA, and to
    increase NIDA's budget in proportion to the overall increase at NIH in
    order to reduce the health, social, and economic burden resulting from
    drug abuse and addiction in this Nation.
        Eunice Kennedy Shriver National Institute for Child Health and
    Human Development (NICHD).--Several Institutes recognize the value and
    relevance of basic behavioral research to their mission, and NICHD is
    to be particularly commended for its support of behavioral research on
    important topics such as mechanisms of cognition and learning,
    developmental trajectories of language, and linkages among brain,
    behavior, and genes. For example, studies have shown that caregiver
    behavior can modify genetic influences on social behavior. Children
    with a particular variation of the serotonin gene who live in families
    that provide low levels of social and emotional support were found to
    be at increased risk for extreme shyness and social withdrawal in
    middle school years. But those children whose families provide high
    levels of support, and who have that same genetic variation, didn't
    show the same levels of shyness. Research supported by NICHD's
    behavioral science programs continues to yield fundamental new insights
    into understanding early cognitive and behavioral development that have
    the potential to change how and when medical and psychological
    specialists evaluate typical cognitive, social, and behavioral
    development during infancy. APS asks Congress to support NICHD's
    sustained behavioral science research portfolio and to encourage other
    Institutes to partner with NICHD to maximize the development of
    interventions in early stages of life that have invaluable benefits in
    adulthood.
        It's not possible to highlight all of the worthy behavioral science
    research programs at NIH. In addition to those reviewed in this
    statement, many other Institutes play a key role in the NIH behavioral
    science research enterprise. These include the National Institute of
    Dental and Craniofacial Research, the National Institute of Mental
    Health, the National Institute on Alcohol Abuse and Alcoholism, the
    National Heart, Lung, and Blood Institute, the National Institute of
    Diabetes and Digestive and Kidney Diseases, and the National Institute
    on Neurological Diseases and Stroke. Behavioral science is a central
    part of the mission of these institutes, and their behavioral science
    programs deserve the subcommittee's strongest possible support.
        This concludes my testimony. Again, thank you for the opportunity
    to discuss NIH appropriations for fiscal year 2010 and specifically,
    the importance of behavioral science research in addressing the
    Nation's public health concerns. I would be pleased to answer any
    questions or provide additional information.
                                     ______

            Prepared Statement of the American Physiological Society
        The American Physiological Society (APS) thanks the Chairman and
    all the members of this subcommittee for their support for the National
    Institutes of Health (NIH). The funds you included in the American
    Recovery and Reinvestment Act of 2009 (ARRA) are providing the NIH with
    a substantial influx of resources at a crucial time. Several
    consecutive years of stagnant budget growth had been eroding the
    scientific capacity painstakingly built up during the doubling. The
    rapid distribution of ARRA funds will allow scientists to explore new
    avenues of promising research through the funding of additional grants,
    which is already building momentum and sparking excitement in the
    research community. The stimulus funds represent a first step toward
    enabling NIH to maintain and to increase employment for highly skilled
    workers, purchase critical equipment and supplies, and enhance research
    capacity at institutions across the country. However, consistent future
    budget growth for NIH will be necessary to sustain this momentum beyond
    the period of stimulus spending and prevent an abrupt halt in these new
    research initiatives after the ARRA. Furthermore, absent a continued
    increase in support for NIH, as many as 20,000 jobs created in the
    biomedical sciences by the stimulus money could be lost. Therefore, the
    APS urges you to make every effort to provide the NIH with a 7 percent
    increase in fiscal year 2010.
        The APS is a professional society dedicated to fostering research
    and education as well as the dissemination of scientific knowledge
    concerning how the organs and systems of the body work. APS was founded
    in 1887 and now has nearly 10,000 member physiologists. APS members
    conduct NIH-supported research at colleges, universities, medical
    schools, and other public and private research institutions across the
    United States. The APS offers these comments on the budget recognizing
    both the enormous financial challenges facing our Nation and the great
    opportunity before us to make progress against disease.
        As a result of improved healthcare, Americans are living longer and
    healthier lives in the 21st century than ever before. However, diseases
    such as heart failure, diabetes, cancer, and emerging infectious
    diseases such as the swine flu continue to inflict a heavy burden on
    our population. The NIH invests heavily in basic research to explore
    the mechanisms and processes of disease. This investment will result in
    new tools and knowledge that can be used to design novel treatments and
    prevention strategies.
        The NIH selects and funds investigator-initiated research of only
    the highest scientific merit through the use of the peer review system.
    Among the breakthroughs in the last year:
      --NIH-funded researchers discovered that people with certain genetic
            variants are at increased risk for a stroke. This genetic link
            provides molecular clues to how strokes develop and also moves
            the field closer to personalized medicine. This work was
            performed by researchers who collaborated to study large
            populations of patients over a long period of time, and is an
            example of research that was supported by multiple institutes
            within the NIH.\1\
    ---------------------------------------------------------------------------
        \1\ M. A. Ikram et al, New England Journal of Medicine 360, 1718-
    28. (April 23, 2009).
    ---------------------------------------------------------------------------
      --Scientists recently discovered that adults retain brown fat, a
            metabolically active type of fat tissue that was previously
            thought to exist only in infants and children. Because brown
            fat burns calories and energy, there is hope that this
            discovery could lead to new treatments for obesity and
            diabetes.\2\
    ---------------------------------------------------------------------------
        \2\ A. M. Cypress et al, New England Journal of Medicine 360, 1509-
    17. (April 9, 2009).
    ---------------------------------------------------------------------------
      --Researchers studying obesity and diet in an animal model found that
            chronic consumption of high levels of fructose leads to excess
            weight gain and molecular changes when paired with a high-fat,
            high-calorie diet. Understanding the physiological changes
            associated with the development of obesity is a first step
            toward the design of interventions that could prevent the
            serious health consequences associated with being
            overweight.\3\
    ---------------------------------------------------------------------------
        \3\ A. Shapiro et al, American Journal of Physiology--Regulatory,
    Integrative and Comparative Physiology 295, R1370-75. (November, 2008).
    ---------------------------------------------------------------------------
        Over the past several years, the Office of the Director has
    supplemented existing research programs with new types of awards as
    part of the NIH Roadmap for Medical Research. These include the New
    Innovator, Pioneer and Transformative Research Award Programs. Such
    programs support bold and creative researchers as they engage in high-
    risk, high-reward research, thus allowing more flexibility to explore
    novel ideas and challenge existing paradigms. The NIH is also using
    these programs as a model for distributing funds under the ARRA. The
    Research and Research Infrastructure ``Grand Opportunities'' program
    will fund potentially high-impact areas of science that will benefit
    from short-term funding.
        The NIH is also home to the Institutional Development Award (IDeA)
    Program. Established in 1993, the goal of the IDeA program is to
    broaden the geographic distribution of NIH funds by serving researchers
    and institutions in areas that have not historically received
    significant NIH funding. IDeA builds research capacity and improves
    competitiveness in those States through the development of shared
    resources, infrastructure, and expertise. IDeA currently serves
    institutions and investigators in 23 States and Puerto Rico.
        In addition to supporting research, the NIH must also address
    workforce issues to ensure that our Nation's researchers are ready to
    meet the challenges they will face in the future. Recent data from the
    NIH shows that the average age of NIH supported principal investigators
    is now 50.8 years.\4\ This is up nearly 12 years from the average
    principal investigator's age of 39.1 years in 1980. In addition, the
    average age at which a researcher obtains their first major research
    award from NIH has increased to 42.4 years. As the scientific workforce
    continues to age, and more researchers retire, there may be an
    insufficient number of young scientists who are trained to replace
    them. Over the last year, the NIH has put in place policies to help new
    investigators succeed in competing for their first major research
    awards. However, efforts will be successful only if funds are available
    to continue to support the careers of new and young investigators
    beyond the period of their first grant.
    ---------------------------------------------------------------------------
        \4\ http://grants.nih.gov/grants/new_investigators/
    resources.htm#data (accessed April 29, 2009).
    ---------------------------------------------------------------------------
        The APS joins the Federation of American Societies for Experimental
    Biology (FASEB) and the Ad Hoc Group for Medical Research Funding in
    urging that NIH be provided with a 7 percent increase in fiscal year
    2010 to permit the agency to maintain its current wide-ranging and
    important research efforts.
                                     ______

         Prepared Statement of the Association of Rehabilitation Nurses
                                  introduction
        On behalf of the Association of Rehabilitation Nurses (ARN), I
    appreciate having the opportunity to submit written testimony to the
    Senate Labor, Health and Human Services, and Education, and Related
    Agencies Subcommittee regarding funding for nursing and rehabilitation
    related programs in fiscal year 2010. ARN represents professional
    nurses who work to enhance the quality of life for those affected by
    physical disability and/or chronic illness. ARN understands that
    Congress has many concerns and limited resources, but believes that
    chronic illness and physical disability are heavy burdens on our
    society that must be addressed.
                rehabilitation nurses and rehabilitation nursing
        Rehabilitation nurses help individuals affected by chronic illness
    and/or physical disability adapt to their disability, achieve their
    greatest potential, and work toward productive, independent lives. They
    take a holistic approach to meeting patients' medical, vocational,
    educational, environmental, and spiritual needs. Rehabilitation nurses
    begin to work with individuals and their families soon after the onset
    of a disabling injury or chronic illness. They continue to provide
    support in the form of patient and family education and empower these
    individuals when they return home, or to work, or school. The
    rehabilitation nurse often teaches patients and their caregivers how to
    access systems and resources.
        Rehabilitation nursing is a philosophy of care, not a work setting
    or a phase of treatment. Rehabilitation nurses base their practice on
    rehabilitative and restorative principles by: (1) managing complex
    medical issues; (2) collaborating with other specialists; (3) providing
    ongoing patient/caregiver education; (4) setting goals for maximal
    independence; and (5) establishing plans of care to maintain optimal
    wellness. Rehabilitation nurses practice in all settings, including
    freestanding rehabilitation facilities, hospitals, long-term subacute
    care facilities/skilled nursing facilities, long-term acute care
    facilities, comprehensive outpatient rehabilitation facilities; and
    private practice, just to name a few.
        To ensure that patients receive the best quality care possible, ARN
    supports Federal programs and research institutions that address the
    national nursing shortage and conduct research on medical
    rehabilitation and nursing and traumatic brain injury. Therefore, ARN
    respectfully requests that the subcommittee provide increased funding
    for the following programs:
    nursing workforce and development programs at the health resources and
                         services administration (hrsa)
        ARN supports efforts to resolve the national nursing shortage,
    including appropriate funding to address the shortage of qualified
    nursing faculty. Rehabilitation nursing requires a high-level of
    education and technical expertise, and ARN is committed to assuring and
    protecting access to professional nursing care delivered by highly
    educated, well-trained, and experienced registered nurses for
    individuals affected by chronic illness and/or physical disability.
        According to the Department of Health and Human Services, the
    Federal Nursing Workforce Development program at the Health Resources
    and Services Administration (HRSA), an estimated 36,750 nurses need to
    be recruited, educated, and retained to meet the current demands of the
    healthcare system. Efforts to recruit and educate individuals
    interested in nursing have been thwarted by the shortage of nursing
    faculty. In 2007, due to the nursing faculty shortage, more than 40,000
    qualified applicants were not able to matriculate in nursing school.
    The number of full-time nursing faculty required to ``fill the nursing
    gap'' is approximately 40,000, and, currently, there are less than
    20,000 full-time nursing faculty members. Further exacerbating this
    issue, HRSA predicts that the nursing shortage is expected to grow to
    41 percent by 2020.
        ARN strongly supports the national nursing community's request of
    $263 million in fiscal year 2010 funding for Federal Nursing Workforce
    Development programs at HRSA.
                                     nidrr
        NIDRR provides leadership and support for a comprehensive program
    of research related to the rehabilitation of individuals with
    disabilities. As one of the components of the Office of Special
    Education and Rehabilitative Services at the U.S. Department of
    Education, NIDRR operates along with the Rehabilitation Services
    Administration and the Office of Special Education Programs.
        The mission of NIDRR is to generate new knowledge and promote its
    effective use to improve the abilities of people with disabilities to
    perform activities of their choice in the community, and also to expand
    society's capacity to provide full opportunities and accommodations for
    its citizens with disabilities. NIDRR conducts comprehensive and
    coordinated programs of research and related activities to maximize the
    full inclusion, social integration, employment and independent living
    of individuals of all ages with disabilities. NIDRR's focus includes
    research in areas such as employment; health and function; technology
    for access and function; independent living and community integration;
    and other associated disability research areas.
        ARN strongly supports the work of NIDRR and encourages Congress to
    provide the maximum possible fiscal year 2010 funding level.
                 national institute of nursing research (ninr)
        ARN understands that research is essential for the advancement of
    nursing science, and believes new concepts must be developed and tested
    to sustain the continued growth and maturation of the rehabilitation
    nursing specialty. The National Institute of Nursing Research (NINR)
    works to create cost-effective and high-quality health care by testing
    new nursing science concepts and investigating how to best integrate
    them into daily practice. NINR has a broad mandate that includes
    seeking to prevent and delay disease and to ease the symptoms
    associated with both chronic and acute illnesses. NINR's recent areas
    of research focus include the following:
      --End of life and palliative care in rural areas;
      --Research in multi-cultural societies;
      --Bio-behavioral methods to improve outcomes research; and
      --Increasing health promotion through comprehensive studies.
        ARN respectfully requests $178 million in fiscal year 2010 funding
    for NINR to continue its efforts to address issues related to chronic
    and acute illnesses.
                          traumatic brian injury (tbi)
        Approximately 1.5 million American children and adults are living
    with long-term, severe disability, as a result of traumatic brain
    injury (TBI). Moreover, this figure does not include the 150,000 cases
    of TBI suffered by soldiers returning from wars in Iraq and
    Afghanistan.
        The annual national cost of providing treatment and services for
    these patients is estimated to be nearly $60 million in direct care and
    lost workplace productivity. Continued fiscal support of the Traumatic
    Brain Injury Act will provide critical funding needed to further
    develop research and improve the lives of individuals who suffer from
    traumatic brain injury.
        Continued funding of the TBI Act will promote sound public health
    policy in brain injury prevention, research, education, treatment, and
    community-based services, while informing the public of the need
    support for individuals living with TBI and their families.
        ARN strongly supports the current work being done by the Centers
    for Disease Control and Prevention (CDC) and HRSA on TBI programs.
    These programs contribute to the overall body of knowledge in
    rehabilitation medicine.
        ARN urges Congress to support the following fiscal year 2010
    funding requests for programs within the TBI Act: $10 million for CDC's
    TBI registries and surveillance, prevention and national public
    education and awareness efforts; $20 million for the HRSA Federal TBI
    State Grant Program; and $13.3 million for the HRSA Federal TBI
    Protection and Advocacy Systems Grant Program.
                                   conclusion
        ARN appreciates the opportunity to share our priorities for fiscal
    year 2010 funding levels for nursing and rehabilitation programs. ARN
    maintains a strong commitment to working with Members of Congress,
    other nursing and rehabilitation organizations, and other stakeholders
    to ensure that the rehabilitation nurses of today continue to practice
    tomorrow. By providing the fiscal year 2010 funding levels detailed
    above, we believe the subcommittee will be taking the steps necessary
    to ensure that our Nation has a sufficient nursing workforce to care
    for patients requiring rehabilitation from chronic illness and/or
    physical disability.
                                     ______

       Prepared Statement of the Association for Research in Vision and
                                 Ophthalmology
        Association for Research in Vision and Ophthalmology (ARVO) has two
    major requests:
      --For Congress to fund the National Institutes of Health (NIH) in
            fiscal year 2010 at $32.4 billion (a 7 percent increase more
            than fiscal year 2009); and
      --For Congress to make vision health a priority in the total funding
            of NIH by increasing the National Eye Institute (NEI) funding
            to $736 million (also a 7 percent increase).
        The requested 7 percent increase represents a 3 percent increase
    plus the 2009 biomedical inflation index.
        ARVO commends Congress for actions taken in fiscal year 2008 and
    2009 to fund NIH. This includes the $150 million fiscal year 2008
    supplement for investigator-initiated grants, the $10.4 billion of NIH
    funding included in the American Recovery and Reinvestment Act, and the
    fiscal year 2009 inflationary increase of 3.2 percent. However, ARVO
    still has concerns about long-term, sustained, and predictable funding
    for vision research.
        Vision disorders are the fourth most prevalent disability in the
    United States and the most frequent cause of disability in children.\1\
    \2\ \3\ \4\ Healthy vision contributes to injury prevention,
    independence, and economic security. Over the next 30 years the elderly
    population of the United States will double and if we fail to take
    action, age-related eye diseases (diabetic retinopathy, glaucoma,
    cataracts, and age-related macular degeneration) will quickly
    overburden our healthcare system. While age-related eye diseases are
    the most common visual impairments in the United States, childhood
    vision loss is also of great concern because of its lifelong economic
    burden.
    ---------------------------------------------------------------------------
        \1\ Federal Interagency Forum on Aging-Related Statistics. Older
    Americans 2000: key indicators of well-being. Washington, DC: U.S.
    Government Printing Office; 2000 Aug. 114 p.
        \2\ http://www.ncbi.nlm.nih.gov/pubmed/15078664
        \3\ http://www.healthypeople.gov/data/2010prog/focus28/2004fa28.htm
        \4\ http://www.preventblindness.org/vpus/
    ---------------------------------------------------------------------------
        ARVO requests $32.4 billion of NIH funding for fiscal year 2010.
    This represents a 7 percent increase more than fiscal year 2009.
        This ensures that prior investments in training junior
    investigators and clinician scientists translate to future improvements
    in health and healthcare services.
        If junior investigators are unable to obtain research grants from
    the NIH, then the prior Government investment in their training will
    not translate into future translational medical breakthroughs. These
    scientists will simply transfer acquired skills to other career
    options.\5\
    ---------------------------------------------------------------------------
        \5\ http://www.the-scientist.com/article/display/16526/
    ---------------------------------------------------------------------------
        With the doubling of the NIH budget (1993-2003) universities
    increased their infrastructure for training life science Ph.Ds and
    hired more full-time faculty.\6\ NIH funding has since remained flat,
    resulting in decreased rates of grant funding. As a consequence many
    academic scientists have either lost their jobs or taken part-time
    positions.\7\ The current economic crisis has further amplified the
    problem. In recent months, the private sector in the United States laid
    off more than 80,000 scientists.\8\ We think the best solution is to
    maintain sustained and predictable funding for scientists at all
    stages. If the average age when scientists obtain their first source of
    independent NIH funding continues to rise (currently 43 years) and
    funding bodies continue to restrict many postdoctoral funding
    opportunities to 2-5 years, a generation of analytical thinkers will be
    forced to find more realistic career options.\9\
    ---------------------------------------------------------------------------
        \6\ http://www.sauvonslarecherche.fr/IMG/pdf/the_postdoc_crisis.pdf
        \7\ http://sciencecareers.sciencemag.org/career_magazine/
    previous_issues/articles/2007_07_13/caredit.a0700099
        \8\ http://sciencecareers.sciencemag.org/career_magazine/
    previous_issues/articles/2009_04_10/caredit.a0900048
        \9\ http://www.brokenpipeline.org/brokenpipeline.pdf
    ---------------------------------------------------------------------------
        To maintain economic and global competitiveness, research and
    development is essential for the United States to remain competitive in
    a global market. Both corporate and Government support of research has
    been declining. Innovation is crucial for maintaining global
    competitiveness.\10\ Since vision problems are a global economic
    concern, the prevention and treatment of ocular disease contributes to
    the economic well-being of the United States and international economy.
    ---------------------------------------------------------------------------
        \10\ http://www.nsf.gov/statistics/nsb0803/start.htm#research
    ---------------------------------------------------------------------------
        NIH and NEI have been leaders in basic research that translates to
    better vision therapies. The NEI Director (Paul Sieving, MD, Ph.D.) has
    reported that 25 percent of all genes identified to date are associated
    with eye disease. Research supported by the NEI is aimed at translating
    these genetic discoveries to improved diagnosis and therapy.\11\ \12\
    \13\ \14\ \15\ The NEI has worked in association with: (1) the National
    Institute on Aging to better diagnose, prevent, and treat age-related
    macular degeneration, diabetes, and cataract; (2) The National
    Institute of Neurological Disorders and Stroke to protect and
    regenerate cells that die from retinal degeneration and glaucoma; and
    (3) the National Institute of Diabetes and Digestive and Kidney
    Disorders on studies of diabetic retinopathy.
    ---------------------------------------------------------------------------
        \11\ http://www.v2020.org/page.asp?section=000100010002
        \12\ http://www.v2020eresource.org/newsitenews.aspx?tpath=news22007
        \13\ http://www.healthypeople.gov/HP2020/
        \14\ http://www.nei.nih.gov/resources/strategicplans/neiplan/
    frm_cross.asp
        \15\ http://www.nei.nih.gov/amd/
    ---------------------------------------------------------------------------
        NEI-sponsored research has resulted in improved therapies for age-
    related macular degeneration and diabetic retinopathy, a promising gene
    therapy for retinitis pigmentosa, and genetic studies of glaucoma in
    minority populations that have a disproportional higher incidence of
    glaucoma.\16\
    ---------------------------------------------------------------------------
        \16\ http://www.eyeresearch.org/resources/NEI_factsheet.html ARVO
    ---------------------------------------------------------------------------
      --To reduce the economic burden of eye disease on the United States
            healthcare system
        In 2008, 3,638,186 persons in the United States were blind. And 1
    in 28 individuals older than age 40 has a visual disability . . . In
    2010 more than half of baby boomers will be at high risk for developing
    age-related eye diseases. Adequate research funding of studies aimed at
    preventing these age related diseases will reduce future healthcare
    expenditures, particularly to the Medicare and Medicaid programs.\17\
    \18\ \19\
    ---------------------------------------------------------------------------
        \17\ http://www.ncbi.nlm.nih.gov/sites/
    entrez?cmd=Retrieve&db=pubmed&dopt=AbstractPlus&list_uids=15078664
        \18\ http://www.researchamerica.org/uploads/factsheet16vision.pdf
        \19\ http://www.preventblindness.org/advocacy/Action_Plan.pdf
    ---------------------------------------------------------------------------
        Treatment of eye diseases in the United States costs $68 billion/
    year. Vision impaired adults are employed at 44 percent the rate of
    healthy individuals and earn an average of $10,000 less per year.\20\
    \21\ \22\ Vision science research leads to therapies that delay,
    prevent and treat blinding ocular disease, leading to increased
    productivity of our work force and savings in the cost of healthcare.
    ---------------------------------------------------------------------------
        \20\ http://www.nei.nih.gov/
        \21\ http://www.eyeresearch.org/pdf/RA_Vision_08_V5.pdf
        \22\ http://www.ncbi.nlm.nih.gov/sites/entrez
    ---------------------------------------------------------------------------
                                    summary
        ARVO urges fiscal year 2010 NIH and NEI funding at $32.4 billion
    and $736 million, respectively, reflecting an at least 7 percent
    increase more than fiscal year 2009.
                                     ______

          Prepared Statement of the American Society for Microbiology
        The American Society for Microbiology (ASM) is pleased to submit
    the following testimony on the fiscal year 2010 appropriation for the
    Centers for Disease Control and Prevention (CDC). The ASM supports the
    fiscal year 2010 funding level of $8.6 billion for CDC recommended by
    the CDC Coalition and the Campaign for Public Health. Funding levels in
    recent years have not adequately supported the CDC mission to protect
    public health through health promotion and disease prevention. The ASM
    appreciates that the administration and Congress have included science
    and public health programs in the American Recovery and Reinvestment
    Act of 2009. It is essential, however, to also provide increased
    funding through the fiscal year 2010 appropriation and future fiscal
    years, at levels that sustain CDC programs to protect public health.
        There are persistent challenges for the Nation's public health
    agencies at the Federal, State, and local levels. Among these are the
    nationwide outbreaks of swine influenza, salmonella food poisoning, and
    upsurges in vaccine preventable diseases such as measles and
    meningitis.
        CDC is instrumental in preventing death and illness caused by
    infectious diseases, contamination of food or water, or release of
    bioterror agents. The recent public health concern surrounding human
    cases of swine influenza A (H1N1) virus infection illustrates the
    importance of CDC's role in the investigation and response to outbreaks
    of infectious diseases. CDC is working closely with officials in States
    where human cases of swine influenza A (H1N1) have been identified, as
    well as with health officials in other countries experiencing outbreaks
    of H1N1. CDC staff are deployed in the United States and
    internationally to provide guidance and technical support in response
    to this emerging health threat. During a rapidly evolving situation,
    CDC is working to reduce transmission and severity of the disease and
    to provide information to healthcare providers, public health
    officials, and the public.
                        cdc combats infectious diseases
        CDC mission specific components cover a wide spectrum of disease
    control and prevention activities. One of these, the Coordinating
    Center for Infectious Diseases (CCID), oversees national centers
    focused on immunization and respiratory diseases; zoonotic, vector-
    borne and enteric diseases; HIV/AIDS, viral hepatitis, sexually
    transmitted diseases and tuberculosis prevention; and healthcare
    associated infections, migration, and quarantine. CCID centers use the
    latest technological tools and scientific information to respond to
    emergent public health challenges as rapidly and effectively as
    possible.
        Emerging Infectious Diseases.--Newly recognized infectious diseases
    attract considerable attention from the public and the research
    community, evidenced by swine influenza A (H1N1) virus infection, H5N1
    avian influenza, severe acute respiratory syndrome (SARS), HIV/AIDS,
    so-called ``mad cow'' disease, West Nile Virus, and methicillin-
    resistant Staphylococcus aureus (MRSA) among others. The CDC must
    respond to these and other emerging diseases with scientific
    proficiency and round-the-clock readiness. The National Center for
    Preparedness, Detection, and Control of Infectious Disease's Division
    of Emerging Infections and Surveillance Services recruits partnerships
    across the CDC and with both national and international organizations,
    to track outbreaks and train laboratory scientists from around the
    world in preventing and responding to such threats. The CDC has
    repeatedly taken part in identifying previously unrecognized pathogens
    like the SARS virus. It also participates in relevant field research
    around the world.
        Influenza Preparedness.--The CDC effort against influenza includes
    programs that focus on both seasonal and potential pandemic forms of
    the disease, such as human cases of swine influenza A virus infection.
    Every year, between 5 and 20 percent of the U.S. population gets the
    flu, more than 200,000 are hospitalized, and about 36,000 die. The CDC
    works with U.S. partners in health departments, clinical laboratories,
    vital statistics offices and healthcare providers to assess the annual
    burden of flu. Comprehensive CDC incidence reports use data from nine
    different sources, like the Nationally Notifiable Disease Surveillance
    System and the Emerging Infections Program's Influenza Project. In
    October 2008, the CDC contracted with the American Type Culture
    Collection to implement the CDC Influenza Reagent Resource, which will
    serve as a source of diagnostic material for laboratories in the event
    of an emerging pandemic. The agency also awarded $24 million for 55
    projects at 29 State and local health departments to develop better
    pandemic preparedness models. Last fall, the Food and Drug
    Administration approved a lab test co-developed by CDC that can
    reliably detect flu viruses with results within four hours.
        CDC extensively monitors the avian influenza virus H5N1 that has
    spread throughout Asia, the Middle East, and parts of Europe.
    Recognition that the relatively new virus could cause a human pandemic
    has mobilized public health institutions worldwide. There have been
    only 413 confirmed human cases in 15 countries (by March 30), but the
    sustained 60-plus percent mortality is unprecedented for an influenza
    virus. The CDC developed a measurement tool to help at-risk countries
    assess their ability to respond to an avian influenza pandemic.
    Moreover, it continues its laboratory and field research on H5N1 and
    other flu viruses. CDC scientists reported last year that some avian
    influenza A H7 virus strains have acquired new features that might
    boost their potential to cause human disease.
        HIV/AIDS.--In August 2008, the CDC released its first estimates of
    HIV infections in the United States based on a new CDC-developed
    laboratory assay called serologic testing algorithm for recent HIV
    seroconversion (STARHS). The results, unfortunately, indicate that
    approximately 56,300 new U.S. HIV infections occurred in 2006, about 40
    percent higher than CDC's former estimate. The STARHS technology is the
    basis for the first national surveillance system relying on direct
    measurement of new HIV infections and provides more precise estimates
    of HIV incidence. CDC continually tracks the nation's progress against
    this recalcitrant disease. For example, the CDC and other health
    agencies updated guidelines in March for the prevention and treatment
    of opportunistic infections in HIV-infected people.
        Global Infectious Diseases.--Infectious diseases are responsible
    for 15 million (26 percent) of the 57 million annual deaths worldwide
    and the CDC is a valuable contributor to public health campaigns
    against these diseases. Examples include its vigorous distribution in
    developing countries of Haemophilus influenzae type b (Hib) vaccine.
    One of the leading causes of severe childhood pneumonia and meningitis,
    Hib disease annually causes an estimated 3 million illnesses and
    400,000 deaths worldwide in children 5 years and younger. Hib vaccines
    have been widely used in industrialized countries for nearly 20 years,
    but underused in the poorest countries. The CDC estimates that this
    year use of Hib vaccine in these countries will exceed 80 percent,
    compared to less than 20 percent in 2004.
        CDC funding supports rigorous research on globally significant
    diseases like malaria and tuberculosis, and underwrites incidence data
    gathered from around the world. The CDC is developing a network of
    Global Disease Detection Centers, along with the participating nations'
    ministries of health, academic institutions, the World Health
    Organization, and U.S. Departments of State and Defense. Centers
    currently operational are located in China, Egypt, Guatemala, Kenya,
    Thailand, and, added in 2008, Kazakhstan. They extend the reach of
    three established CDC programs in emerging infections, epidemiology
    training, and influenza. The Coordinating Office for Global Health
    oversees more than 200 CDC staff in more than 50 countries, as first-
    responders to disease outbreaks. In 2008, CDC responded to more than 90
    international disease outbreaks and public health events and found 22
    new pathogens.
        An estimated 1.8 million airline passengers cross international
    borders daily, opening multiple routes for disease transmission. The
    CDC maintains a specific branch to deal with global migration and
    quarantine issues, using its GeoSentinel Network Surveillance System to
    collect information from 41 sentinel sites and 200 medical clinics in
    75 countries around the world. CDC personnel now staff U.S. quarantine
    stations at 20 ports of entry and land border crossings. The CDC also
    provides U.S. travelers with health threat alerts; educational efforts
    last year included recommendations to the U.S. Olympic teams traveling
    to China.
        Vaccination Campaigns.--CDC collects vaccine-related information to
    assist Federal, State, and local health officials. The CDC also invests
    considerable resources in educating the public on the importance of
    vaccination as a preventive tool. At times, vaccines can also alleviate
    disease rather than prevent initial infection. Last year, the CDC
    recommended that people age 60 and older be vaccinated against shingles
    to reduce the number of painful episodes, even in those with previous
    cases. The most recent CDC survey of childhood immunization in this
    country found that rates remain at or near record levels, with at least
    90 percent coverage for all but one of the recommended series for young
    children. Still, more measles cases were reported in 2008 than any year
    since 1996 largely due to failure to vaccinate. Another CDC report
    concluded that marked reductions in rotavirus-caused gastroenteritis in
    U.S. infants and young children may be due to a recently introduced
    rotavirus vaccine, recommended by CDC in 2006 for routine immunization
    of infants. Rotavirus is the leading cause of severe gastroenteritis in
    the young, typically causing 55,000-70,000 U.S. hospitalizations and
    about 410,000 physician office visits annually. Every day, rotavirus
    kills about 1,600 children under age 5 worldwide.
         cdc confronts healthcare-associated infections, antimicrobial
                                   resistance
        Each year, healthcare-associated infections (HAI) account for an
    estimated 1.7 million infections and 99,000 associated deaths in the
    United States. With more than 1 billion hospital and doctor visits made
    by Americans each year, there unfortunately is ample opportunity for
    HAI exposure. A CDC report released in March estimates that the annual
    direct hospital cost of treating HAI ranges from $28.4 billion to $45
    billion, and that improving infection control could save roughly $6
    billion to $32 billion, depending on the percentage of infections
    preventable in healthcare settings. With 2009 healthcare costs expected
    to reach $2.5 trillion, saving resources through CDC-facilitated
    prevention clearly offers a sensible public health strategy.
        CDC works to optimize practices for HAI prevention. For example,
    CDC reports that 85 percent of all invasive infections caused by
    methicillin-resistant Staphylococcus aureus (MRSA) are associated with
    healthcare settings. CDC guidelines help assure best practices in
    healthcare settings. Hospitals in a CDC-supported study reduced
    bloodstream and MRSA infections as much as 70 percent by implementing
    CDC prevention guidelines. Last September, CDC launched a public MRSA
    education campaign.
        Antimicrobial resistance has emerged as a daunting global
    challenge, increasing the lethality of pathogens from extensively drug-
    resistant tuberculosis (XDR TB) to this year's flu virus strain highly
    resistant to the most commonly used prescription drug. Last year, 16
    CCID surveillance systems and programs gathered incidence data on
    antimicrobial resistance among bacterial, fungal, parasitic and viral
    agents. CDC scientists are developing laboratory protocols and
    diagnostics for a growing list of drug-resistant pathogens. One example
    is a new protocol for molecular typing of methicillin-resistant S.
    aureus. The CDC's Antimicrobial Resistance Team also recently validated
    tests that will amend 2009 clinical and lab standards in testing
    microbial resistance to mupirocin (used for staph infections) and the
    carbapenem drugs used to treat enteric pathogens resistant to most
    other drugs.
     cdc strengthens national defenses against bioterrorism, public health
                                     crises
        The CDC's Terrorism, Preparedness and Emergency Response (TPER)
    funds support the Coordinating Office for Terrorism Preparedness and
    Emergency Response objectives. CDC provides science-based strategies
    and tactical coordination during public health events and maintains
    emergency response operations like the Strategic National Stockpile
    (SNS) and the Emergency Operations Center (EOC). The SNS is an
    invaluable national repository of antibiotics, antitoxins and other
    medical supplies that can be mobilized rapidly to augment State and
    local resources during a large-scale health emergency. Opened in 2003,
    the DEOC is staffed with experts 24/7/365, an integral part of the
    country's National Incident Management System.
        The CDC's inaugural annual report on its TPER-funded activities
    released in January enumerates its wide-ranging activities. Activities
    include assessing current administration routes and dosage for anthrax
    vaccine, inspecting 110 research entities registered to possess
    microbes on the Federal select agents list, and mapping the DNA of the
    vaccinia virus (similar to smallpox virus) and tularemia bacteria for
    greater scientific insight into potential bioagents. TPER-funded
    capabilities help CDC respond more aggressively to public health crises
    of all kinds, far beyond the threat of bioterrorism. In fiscal year
    2008, the EOC was activated in response to 55 domestic and 16
    international events, including the floods in the Midwest, multistate
    Salmonella and E.coli 0157 outbreaks, and outbreaks of cholera and
    hemorrhagic fever in Africa.
        The ASM concurs with the recommended level of $8.6 billion, which
    will provide needed new funding for CDC's programs that are so critical
    to protecting people in the United States and worldwide.
                                     ______

          Prepared Statement of the American Society for Microbiology
        The American Society for Microbiology (ASM) appreciates the
    opportunity to submit a written statement on the fiscal year 2010
    budget for the National Institutes of Health (NIH). The ASM is the
    largest single life science society with more than 42,000 members, many
    of whom receive funding from the NIH. We are grateful for the $10.4
    billion increase in funding for the NIH in the American Recovery and
    Reinvestment Act (ARRA) and the 3.2 percent increase in funding for NIH
    in the fiscal year 2009 Labor, Health and Human Services, and
    Education, and Related Agencies Appropriations Act. The additional ARRA
    funding enables NIH to support the ARRA goals to create and save jobs
    and increase purchasing power, as well as advance scientific research.
    The Nation's biomedical research enterprise will be kept more robust at
    a time when it is experiencing the adverse effects of the economic
    downturn and years of flat funding.
        As Congress considers the fiscal year 2010 appropriation for NIH,
    the ASM recommends a budget of $32.4 billion, a 7 percent increase. The
    recommended funding increase will help NIH keep pace with expanded
    research opportunities and higher costs. It is important for NIH to
    prepare for the poststimulus years, in 2011 and beyond. It is also
    important to resume sustainable NIH funding, avoiding fluctuations for
    research and training programs that can disrupt projects, training,
    careers, and research progress. To perpetuate the benefits of ARRA
    funding, it is vitally important to provide sustained growth for the
    NIH in fiscal year 2010 and beyond.
        More than 83 percent of the NIH budget is awarded through 50,000
    competitive grants awarded to more than 325,000 researchers at more
    than 3,000 universities, medical schools, and other institutions in all
    50 States. About 10 percent of the NIH budget supports research in NIH
    laboratories conducted by nearly 6,000 scientists. Research project
    grants are highly productive in terms of medical advances to benefit
    public health. NIH funding contributes to the Nation's economic
    recovery by stimulating new opportunities and investments in
    biotechnology and related industries, as well as expanding the skilled
    workforce critical to U.S. competitiveness in science and technology.
    NIH funding also impacts allied health workers, technicians, students,
    trade workers, and others who receive the leveraged benefits from NIH
    funding.
        The following describes some of the compelling reasons for
    increased and sustained support for the NIH research mission and its
    proven benefit to technological innovation and public health.
                nih research is critical to scientific progress
        NIH Institutes and Centers fund research programs that address the
    Nation's challenges of safeguarding public health, security, and the
    economy. The National Institute of Allergy and Infectious Diseases
    (NIAID), for example, focuses on research to understand, treat, and
    prevent infectious, immunologic, and allergic diseases, leading to the
    development of vaccines, therapies and diagnostic tools. The NIAID also
    funds research on medical countermeasures against potential bioterror
    agents. The National Institute of General Medical Sciences (NIGMS)
    supports basic research on life processes in fields such as
    computational biology, genetics, and bioinformatics. NIH resources
    invested in the agency-wide Roadmap initiatives make possible projects
    that hold great potential but might otherwise not be funded due to
    difficulty and scope. Recently funded Roadmap projects include a
    network of nine centers using high-tech screening methods for drug
    discovery.
        The NIH funding to individual researchers and research groups,
    through competitive peer-reviewed grants, is of particular consequence
    to the U.S. research enterprise. More than 120 discoveries made by NIH
    and NIH-supported researchers have garnered Nobel Prizes, and NIGMS has
    funded the Nobel Prize-winning work of 64 scientists. More than three-
    fourths of the U.S. recipients of the Nobel Prize in Physiology or
    Medicine received NIH support prior to their award. In fiscal year 2009
    NIH is striving to lower the average age of first-time grant recipients
    to refresh the Nation's scientific investigator pool and help
    revitalize research in the United States. Our national anxiety over
    waning global competitiveness and a shrinking technical workforce
    argues for sustained NIH funding for both new and established
    investigators.
        NIH investigator-initiated grants create new opportunities for
    original biomedical inquiry and expand training environments for
    students in technical fields. Investigator-initiated research projects
    lead to inventive solutions for medical problems. Each year, NIH also
    identifies, in consultation with the extramural research community,
    targeted areas within an emerging need or opportunity, and then
    requests grant applications from U.S. researchers. Focused
    opportunities announced last year by NIAID include studies to advance
    vaccine safety and development of assays for high-throughput drug
    screening. NIGMS-featured areas currently include computational models
    to detect, control, and prevent emerging infectious diseases. NIGMS
    also awards grants for nontraditional research through its Exceptional,
    Unconventional Research Enabling Knowledge Acceleration (EUREKA)
    program. NIH has placed new emphasis on supporting high-impact
    transformative research that might create new disciplines,
    revolutionary technologies, or otherwise radically change biomedical
    research. In 2008, it initiated transformative grant funding to foster
    investigator-initiated work considered high-risk but exceptionally
    promising.
                      nih research yields medical advances
        NIH supported research consistently produces significant
    discoveries with both real-world relevance and potential future use
    against emerging health threats. The following are selected examples of
    recently reported research that illustrate the vitality and creativity
    supported by NIH funding.
        Antimicrobial Resistance and Drug Discovery.--Drug resistance
    spreading among microbial pathogens is complicating control of
    infectious diseases and adding to rising healthcare costs. Response by
    U.S. research institutions has been aggressive, including creation of a
    Federal Interagency Task Force co-chaired by NIAID, the Centers for
    Disease Control and Prevention, and the Food and Drug Administration.
    Causes of drug resistance are many, from overuse of prescription drugs
    to natural microbial mutations, and NIAID's research portfolio is
    equally diverse. In fiscal year 2007, the Institute invested more than
    $800 million to support basic and translational research on
    antimicrobials and on drug resistance. Recent results include:
      --Scientists from NIAID, California, and China studied the genetics
            of the major strain of methicillin-resistant Staphylococcus
            aureus (MRSA), concluding that a radical shift may be needed in
            how scientists design MRSA therapeutics. MRSA causes an
            estimated 94,000 cases of infection annually in the United
            States, with more than 19,000 deaths.
      --NIGMS-funded researchers are developing a new generation of
            antibiotic compounds that do not elicit drug resistance. The
            enzyme-inhibitor compounds interfere with ``quorum sensing''--a
            process by which bacteria communicate with each other. Those in
            the current study work against Vibrio cholerae, which causes
            cholera, and E. coli 0157:H7, the food contaminant that
            annually causes about 110,000 illnesses in the United States.
        To circumvent antimicrobial resistance, NIH researchers and their
    extramural collaborators are intensifying research strategies better
    suited to rapidly changing pathogens and disease demographics. These
    include state-of-the-art technologies that fuel 21st century drug
    discovery. A recent example is NIGMS-funded research using mass
    spectrometry technology to determine the molecular structure of a class
    of natural compounds called nonribosomal peptides (NRPs), intensely
    studied for their drug potential (penicillin is an NRP). A significant
    advance over previous approaches, it may help reprogram nonpathogenic
    E. coli into NRP minifactories.
        Infectious Diseases.--Infectious diseases remain among the most
    difficult global health challenges, accounting for about one-quarter of
    all deaths and nearly two-thirds in sub-Saharan Africa. At NIAID and
    NIGMS, multiple programs and interdisciplinary strategies target the
    major causes of global death and disability, with cutting-edge tools
    like genomics and nanotechnology.
        Influenza.--Despite the availability of influenza drugs and
    vaccines, seasonal influenza still kills more than 250,000 people
    worldwide each year. Public health officials are now concerned about
    reports that 98 percent of a H1N1 influenza virus strain (1 of 3
    circulating in the 2008-2009 season) are resistant to oseltamivir
    (Tamiflu), the leading influenza drug, compared to 11 percent
    resistance among all viral strains during the 2007-2008 season. The
    possibility of an influenza pandemic caused by the more lethal H5N1
    avian flu virus has mobilized an international response from health
    agencies and medical researchers. In January, the Department of Health
    and Human Services awarded a contract to build the first U.S.
    manufacturing facility for cell-based influenza vaccines, expected to
    increase the Nation's current capacity to make vaccine by at least 25
    percent and much less time. NIH funding contributed to this major
    advance in vaccine production and to other recent advances, such as:
      --NIAID-supported scientists used new monoclonal techniques to create
            human influenza-fighting antibodies in the laboratory in a
            matter of weeks, rather than the months previously required.
            The antibodies have potential for diagnosis and treatment
            regimens that can respond more quickly to newly emerging
            strains of influenza.
      --NIGMS-funded researchers used super-computer capabilities to
            identify more than two dozen new candidate drugs to treat avian
            influenza (``bird flu''), in preparation for a possible
            pandemic of drug-resistant H5N1 virus strains.
      --Three research teams and a computer informatics group--part of the
            NIGMS-funded Models of Infectious Disease Agent Study (MIDAS)
            Network--modeled pandemic influenza in the United States,
            concluding mitigation is possible with prompt, coordinated use
            of social-distancing measures and antiviral treatment until
            vaccine is available.
        HIV/AIDS.--An estimated 33 million adults and children are living
    with HIV infection worldwide, and about 2 million die each year from
    related causes. In the United States, where nearly 546,000 people have
    died thus far from HIV/AIDS-related illnesses, there currently are an
    estimated 1.1 million infected, with 21 percent unaware of their
    infection. HIV/AIDS as both a domestic and global threat is a high
    priority at NIH. Difficulties in developing preventative vaccines
    prompted a 2008 NIH vaccine summit and subsequent re-examination of
    NIH's research agenda. NIH-supported basic research is steadily adding
    to our understanding of HIV/AIDS, evidenced by recent discoveries in
    mechanisms of HIV protease inhibition and the NIGMS-funded success in
    seeing microscopically for the first time molecules grouping in living
    cells to form single HIV particles. Other recent advances include:
      --A vaginal gel to prevent HIV infection in women has shown
            encouraging signs of success in a clinical trial in Africa and
            the United States. This is the first human clinical study to
            suggest that a microbicide may prevent male-to-female sexual
            HIV transmission.
      --An extended course of the antiretroviral drug nevirapine helps the
            breastfeeding babies of HIV-infected mothers remain HIV-
            negative and live longer, according to several new studies.
            About 150,000 infants worldwide acquire HIV annually through
            breastfeeding.
      --The incidence of childhood illness and death due to HIV infection
            can be dramatically decreased by testing very young babies for
            HIV and giving antiretroviral therapy (ART) immediately to
            those found infected--giving ART to HIV-infected infants
            beginning at an average age of 7 weeks made them four times
            less likely to die in the next 48 weeks.
        Tuberculosis.--One-third of the world's 6.7 billion people are
    thought to be infected by Mycobacterium tuberculosis (Mtb), the microbe
    that causes tuberculosis. An estimated 13.7 million have the active
    form. Each year, about 1.7 million die from this age-old disease that
    has adopted some disturbing modern-day features, striking as co-
    infections with the HIV virus and becoming resistant to drug therapies
    used to treat tuberculosis. In 2007, about 9.3 million people developed
    new cases of TB; 1.37 million were also HIV positive. The rapid spread
    of multidrug- and extensively drug-resistant forms (MDR TB/XDR TB) is
    alarming--MDR TB currently accounts for an estimated 5 percent of all
    TB cases and the frequently fatal XDR TB has been detected in 46
    countries thus far. In April 2008, NIAID launched an aggressive
    research agenda against drug-resistant tuberculosis. NIH-supported
    research from the past year includes:
      --NIAID scientists and industry collaborators found that, when the
            candidate TB drug PA-854 is metabolized inside Mtb bacteria, a
            lethal dose of nitric oxide gas is produced, killing the
            pathogen and suggesting new ways to develop drugs capable of
            killing latent TB bacteria. Currently there are no drugs
            available to target latent tuberculosis infections.
      --Scientists reported that two FDA-approved drugs work in tandem to
            kill the tuberculosis pathogen and could help counter drug-
            resistant forms. The drugs are already used to treat other
            bacterial diseases, but their effectiveness against TB bacteria
            had not been studied. NIAID is planning a clinical trial this
            year in patients with MDR TB and XDR TB.
        Malaria.--Nearly half of the world's population is at risk of
    contracting malaria, a preventable and curable mosquito-borne disease
    in more than 100 countries. The World Health Organization (WHO)
    estimates that 300 to 500 million cases of clinical malaria worldwide
    occur each year, killing 1.3 million people. Unfortunately, its impact
    is intensifying with the emergence of drug-resistant parasites and
    insecticide-resistant mosquitoes. In April 2008, NIAID announced its
    new strategic plan to accelerate malaria control and eradication. NIH
    research often involves international partners and encompasses all
    aspects of malaria, including these recent examples:
      --NIGMS funding supported the genetic decoding of the parasite
            responsible for 40 percent of infections, Plasmodium vivax, 1
            of 4 malaria parasites that routinely affect humans. The most
            common species outside Africa (including the United States), P.
            vivax is increasingly resistant to some antimalarial drugs.
      --The NIAID-funded Malaria Research and Training Center in Mali
            completed the first clinical trial of a vaccine to block the
            malaria parasite from entering human blood cells.
      --NIGMS-supported research described how harmless E. coli bacteria
            can be harnessed to synthesize an antimalarial compound in
            bulk, far less expensive than the current process.
     infectious disease research uses interdisciplinary strategies and new
                                  technologies
        NIAID and NIGMS, like other NIH Institutes and Centers, support
    productive basic research on literally hundreds of diseases, from
    periodic foodborne E. coli or Salmonella outbreaks to isolated cases of
    Ebola fever or anthrax. This enormous responsibility forces constant
    adaptation to new challenges, often through greater reliance on
    interdisciplinary strategies or novel research tools and technologies--
    epitomized by the large-scale, genetics-based initiatives made possible
    with today's powerful computing capabilities. In 2008, NIH launched a
    multi-Institute epigenomics initiative to better understand the role of
    the environment in regulating mammalian genes, through genome mapping,
    data analysis, and technology development. NIH also agreed to share
    databases from its Human Microbiome Project in support of the newly
    formed International Human Microbiome Consortium. Characterizing the
    human microbiome, which is the collective DNA of all the microbes
    living in or on the human body, will elucidate the relationship between
    microbes and humans during health and disease. Shared sample
    repositories overseen by databases expedite information exchange among
    scientists. Computerized screening of pathogen genomes similarly
    accelerates the search for treatments, vaccines, and diagnostics.
                                   conclusion
        ASM is thankful that Congress recognizes both the medical benefits
    and economic impacts of biomedical research and has provided an
    infusion of funding for the NIH to uncover new knowledge that will
    improve public health. Investing in NIH will impact the health of
    people for years to come and the biomedical community is working to
    ensure wise investment of the new resources in fiscal year 2009. We are
    confident that investments in the NIH will result in new discoveries
    and innovations that can address many of our health and economic
    challenges.
                                     ______

            Prepared Statement of the American Society for Nutrition
        The American Society for Nutrition (ASN) appreciates this
    opportunity to submit testimony regarding fiscal year 2010
    appropriations for the National Institutes of Health (NIH) and the
    National Center for Health Statistics (NCHS). ASN is the professional
    scientific society dedicated to bringing together the world's top
    researchers, clinical nutritionists, and industry to advance our
    knowledge and application of nutrition to promote human and animal
    health. Our focus ranges from the most critical details of research to
    very broad societal applications. ASN respectfully requests $32.4
    billion for NIH, and we request $137.5 million for NCHS in fiscal year
    2010.
        Basic and applied research on nutrition, nutrient composition, the
    relationship between nutrition and chronic disease and nutrition
    monitoring are critical to the health of all Americans and the U.S.
    economy. Awareness of the growing epidemic of obesity and the
    contribution of chronic illness to burgeoning healthcare costs has
    highlighted the need for improved information on dietary components,
    dietary intake, strategies for dietary change, and nutritional
    therapies. Preventable chronic diseases related to diet and physical
    activity cost the economy more than $117 billion annually, and this
    cost is predicted to rise to $1.7 trillion in the next 10 years. It is
    for this reason that we urge you to consider these recommended funding
    levels for two agencies under the Department of Health and Human
    Services that have profound effects on nutrition research, nutrition
    monitoring, and the health of all Americans--NIH and NCHS.
                                      nih
        NIH is the Nation's premier sponsor of biomedical research and is
    the agency responsible for conducting and supporting 90 percent (nearly
    $1 billion) of federally funded basic and clinical nutrition research.
    Nutrition research, which makes up about 4 percent of the NIH budget,
    is truly a trans-NIH endeavor, being conducted and funded across
    multiple Institutes and Centers. Some of the most promising nutrition-
    related research discoveries have been made possible by NIH support.
        In order to fulfill the extraordinary promise of biomedical
    research, including nutrition research, ASN recommends an fiscal year
    2010 funding level of $32.4 billion for the agency, which is a 7
    percent increase ($2.1 billion) more than fiscal year 2009.
        Over the past 50 years, NIH and its grantees have played a major
    role in the explosion of knowledge that has transformed our
    understanding of human health, and how to prevent and treat human
    disease. Because of the unprecedented number of breakthroughs and
    discoveries made possible by NIH funding, scientists are helping
    Americans to live longer, healthier, and more productive lives. Many of
    these discoveries are nutrition-related and have impacted the way
    clinicians prevent and treat heart disease, cancer, diabetes, and age-
    related macular degeneration.
        During the next 25 years, the number of Americans with chronic
    disease is expected to reach 46 million, and the number of Americans
    older than age 65 is expected to be the largest in our Nation's
    history. Sustained support for basic and clinical research is required
    if we are to confront successfully the healthcare challenges associated
    with an older, and potentially sicker, population.
        For several years in a row the NIH budget failed to keep up with
    inflation and subsequently, the percentage of dollars funding
    nutrition-focused projects declined. We applaud Congress' inclusion of
    funds for NIH in H.R. 1, the American Recovery and Reinvestment Act,
    and also the boost provided in the fiscal year 2009 omnibus
    appropriations bill. It is imperative that we continue our commitment
    to biomedical research and to fulfill the hope of the American people
    by making the NIH a national priority. Otherwise, we risk losing our
    Nation's dominance in biomedical research.
        The 7 percent increase we recommend is an important step toward
    President Obama's campaign pledge to double funding for basic research
    over 10 years and is necessary to maintain both the existing and future
    scientific infrastructure. The discovery process--while it produces
    tremendous value--often takes a lengthy and unpredictable path. Recent
    experience has demonstrated how cyclical periods of rapid funding
    growth followed by periods of stagnation is disruptive to training, to
    careers, long-range projects and ultimately to progress. NIH needs
    sustainable and predictable budget growth to achieve the full promise
    of medical research to improve the health and longevity of all
    Americans.
                                    cdc nchs
        NCHS, housed within the Centers for Disease Control and Prevention
    (CDC), is the Nation's principal health statistics agency. The NCHS
    provides critical data on all aspects of our healthcare system, and it
    is responsible for monitoring the Nation's health and nutrition status.
    Nutrition and health data, largely collected through the National
    Health and Nutrition Examination Survey (NHANES), is essential for
    tracking the health and well-being of the American population, and it
    is especially important for observing health trends in our Nation's
    children. Knowing both what Americans eat and how their diets directly
    affect their health provides valuable information to guide policies on
    food safety, food labeling, food assistance, military rations, and
    dietary guidance.
        Over the past few years, flat and decreased funding levels have
    threatened the collection of this important information, most notably
    vital statistics and the NHANES. ASN was pleased to see that Congress
    appropriated an additional $11 million to the agency--for nearly $125
    million total--in fiscal year 2009. This halted what would have been
    the beginning of drastic cuts to the agency's premier health surveys--
    NHANES and the National Health Information Survey--that were slated to
    occur should the agency not receive additional funds.
        To continue support for the agency and its important mission, ASN
    recommends an fiscal year 2010 funding level of $137.5 million for the
    agency, which is a $12.5 million increase over fiscal year 2009.
        Current funding levels for NCHS remain precarious. Before the
    recent increase in funds, NCHS had lost $13 million in purchasing power
    since fiscal year 2005 due to years of flat funding, coupled with
    inflation and the increased costs of technology and information
    security. These shortfalls forced the elimination of data collection
    and quality control efforts, threatened the collection of vital
    statistics, stymied the adoption of electronic systems and limited the
    agency's ability to modernize surveys to reflect changes in demography,
    geography, and health delivery.
        Moreover, nearly 30 percent of the funding for NHANES comes from
    other Federal agencies such as the NIH and the Environmental Protection
    Agency. When these agencies face flat budgets or cuts, they withdraw
    much-needed support for NHANES, placing this national treasure in even
    greater jeopardy.
        The obesity epidemic is a case in point that demonstrates the value
    of the work done by NCHS. It is because of NHANES that our Nation
    became aware of this growing public health problem, and as obesity
    rates have increased to 31 percent of American adults (which we know
    because of continued monitoring), so too have rates of heart disease,
    diabetes, and certain cancers. It is only through continued support of
    this program that the public health community will be able to stem the
    tide against obesity. Continuous collection of this data will allow us
    to determine not only if we have made progress against this public
    health threat, but also if public health dollars have been targeted
    appropriately. A recent report from the Institute of Medicine
    recognized the importance of NHANES and called for the enhancement of
    current surveillance systems to monitor relevant outcomes and trends
    with respect to childhood obesity.
        Providing an additional $12.5 million in fiscal year 2010 continues
    the progress on the path to boost funding for the NCHS to $175 million
    by 2013. Reaching this level over 5 years, through annual increases of
    approximately $11-12 million, would allow the agency to reach what its
    supporters call ``blue sky.'' Such an increase would ensure
    uninterrupted collection of vital statistics and sustain over-sampling
    of vulnerable populations.
        ASN thanks your subcommittee for its support of the NIH and NCHS in
    previous years.
                                     ______

         Prepared Statement of the American Society of Plant Biologists
        On behalf of the American Society of Plant Biologists (ASPB) we
    would like to thank the subcommittee for its extraordinary support of
    the National Institutes of Health (NIH) and ask that the subcommittee
    members encourage increased funding for plant biology research, which
    has contributed in innumerable ways to improving the lives of people
    throughout the world.
        ASPB is an organization of more than 5,000 professional plant
    biologists, educators, graduate students, and postdoctoral scientists.
    A strong voice for the global plant science community, our mission--
    which is achieved through engagement in the research, education, and
    public policy realms--is to promote the growth and development of plant
    biology and plant biologists and to foster and communicate research in
    plant biology. The Society publishes the highly cited and respected
    journals Plant Physiology and The Plant Cell, and it has produced and
    supported a range of materials intended to demonstrate fundamental
    biological principles that can be easily and inexpensively taught in
    school and university classrooms by using plants.
                  plant biology research and america's future
        Plants are vital to our very existence. They harvest sunlight,
    converting it to chemical energy for food and feed; they take up carbon
    dioxide and produce oxygen; and they are almost always the primary
    producers in the Earth's ecosystems. Plants and plant-based products
    directly or indirectly provide our food, our shelter, and our clothing.
        Basic plant biology research is making many fundamental
    contributions in vital areas including health and nutrition, energy,
    and climate change. For example, because plants are the ultimate source
    of both human nutrition and nutrition for domestic animals, plant
    biology has the potential to contribute greatly to reducing healthcare
    costs as well as playing an integral role in drug discovery and
    therapies. Although the NIH does offer some funding support to plant
    biology research, with increased funding plant biologists can offer
    much more to advance the missions of the NIH. In the next section, we
    highlight the particular relevance of plant biology research to human
    health.
                           plant biology and the nih
        The mission of the NIH is to pursue ``fundamental knowledge about
    the nature and behavior of living systems and the application of that
    knowledge to extend healthy life and reduce the burdens of illness and
    disability'' (http://www.nih.gov/about/index.html#mission). Plant
    biology research is highly relevant to this mission.
        Plants are often the ideal model systems to advance our
    ``fundamental knowledge about the nature and behavior of living
    systems,'' as they provide the context of multi-cellularity, while
    affording ease of genetic manipulation, a lesser regulatory burden, and
    inexpensive maintenance requirements. Many basic biological components
    and mechanisms are shared by both plants and animals. For example, a
    molecule named cryptochrome that senses light was identified first in
    plants and subsequently found to also function in humans, where it
    plays a central role in regulating our biological clock. Jet lag
    provides one familiar example of what happens to us when our biological
    clock is disrupted, but there are also human genetic disorders that
    have been linked to malfunctioning of the clock. As another example,
    some fungal pathogens can infect both humans and plants.
                              health and nutrition
        Plant biology research is also central to the application of basic
    knowledge to ``extend healthy life and reduce the burdens of illness
    and disability.'' This connection is most obvious in the inter-related
    areas of nutrition and clinical medicine. Without good nutrition, there
    cannot be good health. One World Health Organization (WHO) study on
    childhood nutrition in developing countries concluded that more than 50
    percent of the deaths of children less than 5 years of age could be
    attributed to malnutrition's effects in exacerbating illnesses such as
    respiratory infections and diarrhea. In other words, those illnesses
    would not have proved fatal had the children simply received proper
    nutrition. Strikingly, most of these deaths were not linked to severe
    malnutrition but only to mild or moderate nutritional deficiencies.
    Plant biology researchers are working today to improve the nutritional
    content of crop plants by, for example, increasing the availability of
    nutrients and vitamins such as iron, vitamin E and vitamin A. (Up to
    500,000 children in the developing world go blind every year as a
    result of vitamin A deficiency).
        By contrast, obesity, cardiac disease, and cancer take a striking
    toll in the developed world. Among many plant biology initiatives
    relevant to these concerns are research to improve the lipid
    composition of plant fats and efforts to optimize concentrations of
    plant compounds that are known to have anti-carcinogenic properties,
    such as the glucosinolates found in broccoli and cabbage.
                                 drug discovery
        Plants are also fundamentally important as sources of both extant
    drugs and drug discovery leads. In fact, more than 10 percent of the
    drugs considered by the WHO to be ``basic and essential'' are still
    exclusively obtained from flowering plants. Some historical examples
    are quinine, which is derived from the bark of the cinchona tree and
    was the first highly effective antimalarial drug; and the plant
    alkaloid morphine, which revolutionized the treatment of pain.
        These pharmaceuticals are still in use today. A more recent example
    of the importance of plant-based pharmaceuticals is the anti-cancer
    drug taxol. The discovery of taxol came about through collaborative
    work involving scientists at the National Cancer Institute within NIH
    and plant biologists at the U.S. Department of Agriculture. The plant
    biologists collected a wide diversity of plant materials, which were
    then evaluated for anti-carcinogenic properties. It was found that the
    bark of the Pacific yew tree yielded one such compound, which was
    eventually isolated and named taxol after the tree's Latin name, Taxus
    brevifolia. Originally, taxol could only be obtained from the tree bark
    itself, but basic research led to identification of its molecular
    structure and eventually to its chemical synthesis in the laboratory.
        On the basis of a growing understanding of metabolic networks,
    plants will continue to be sources for the development of new medicines
    to help treat cancer and other ailments. Taxol is just one example of a
    plant secondary compound. Since plants produce an estimated 200,000
    such compounds, they will continue to provide a fruitful source of new
    drug leads, particularly if collaborations such as the one described
    above can be fostered and funded. With additional research support,
    plant biologists can lead the way to developing new medicines and
    biomedical applications to enhance the treatment of devastating
    diseases.
                                   conclusion
        Despite the fact that plant biology research underlies so many
    vital practical considerations for our country, the amount invested in
    understanding the basic function and mechanisms of plants is small when
    compared with the impacts of this information on multibillion dollar
    sectors of the economy such as health, energy, and agriculture.
        Clearly, the NIH does recognize that plants are a vital component
    of its mission. However, because the boundaries of plant biology
    research are permeable and because information about plants integrates
    with many different disciplines that are highly relevant to NIH, ASPB
    hopes that the subcommittee will provide additional resources through
    increased funding to NIH for plant biology in order to help pioneer new
    discoveries and new methods in biomedical research.
                                     ______

        Prepared Statement of the American Society for Pharmacology and
                           Experimental Therapeutics
        The American Society for Pharmacology and Experimental Therapeutics
    (ASPET) is pleased to submit written testimony in support of the
    National Institutes of Health (NIH) fiscal year 2010 budget. ASPET is a
    4,500-member scientific society whose members conduct basic and
    clinical pharmacological research within the academic, industrial, and
    government sectors. Our members discover and develop new medicines and
    therapeutic agents that fight existing and emerging diseases as well as
    increasing our knowledge regarding how therapeutics work in humans.
        ASPET members recognize the trust and support that Congress
    displayed with the recent $10.4 billion provided to the NIH in the
    American Recovery and Reinvestment Act (ARRA). This was a visionary
    attempt by Congress to stimulate the economy by restoring their
    historic support of the NIH which has lagged over the last 6 years as
    appropriations have failed to adequately fund the NIH to meet
    scientific opportunities and challenges to our public health. Prior to
    ARRA funding, the NIH research portfolio could barely keep pace with
    the inflation rate and the country's leadership in biomedical research
    was in danger. Since the completion of a bipartisan plan to double the
    NIH budget that ended in 2003 and prior to ARRA funding, the NIH budget
    had been going backwards.
        For fiscal year 2010, ASPET urges Congress to increase funding for
    the NIH by 7 percent. This would be the first step toward the
    President's pledge to double funding for basic research over 10 years
    and importantly, would help to maintain existing and future scientific
    infrastructure. Scientific discovery takes time and a 7 percent
    increase in fiscal year 2010 and beyond will help NIH manage its
    research portfolio effectively without necessitating disruptions in
    continuity of existing grants to researchers throughout the country.
    Only through sustainable and predictable funding can NIH continue to
    fund the highest-quality biomedical research to help improve the health
    of all Americans and continue to make significant economic impact in
    many communities across the country. Failing to capitalize upon the
    ARRA investments in fiscal year 2010 and beyond will mean that NIH will
    have to dismantle newly built research capacity and terminate important
    research projects after the ARRA funds have been spent. This would have
    serious consequences for future scientific discovery. Scientific
    discovery takes time and is unpredictable. As recent experience has
    shown from the postdoubling experience, boom and bust cycles of rapid
    funding followed by significant periods of stagnation or retraction in
    the NIH budget diminish scientific process. If NIH cannot sustain its
    recent investments from the ARRA, a rapid diminishment of funding will
    further disrupt scientific careers among promising young and early
    career scientists who see little hope of promising and rewarding
    careers in biomedical research. It is critical to avoid a boom and bust
    cycle for NIH funding. Thus, appropriating NIH a 7 percent increase
    beginning in fiscal year 2010 will help achieve the full promise of
    biomedical research.
              nih improves human health and is an economic engine
        A 7 percent increase in fiscal year 2010 will help to reverse what
    ASPET feels is a wrong signal that has been sent to the best and
    brightest of our students who will not be able to or have chosen not to
    pursue a career in biomedical research. Failing to address the NIH
    scientific and infrastructure needs post-ARRA in 2010 and beyond will
    mean a significant reduction in research grants, jobs lost and the
    resulting phasing-out of research programs. Additionally, there would
    be a loss of scientific opportunities to discover new therapeutic
    targets to develop, and fewer discoveries that produce spin-off
    companies that employ individuals in districts around the country. A 7
    percent increase would provide the Institutes with an opportunity to
    fund more high-quality and innovative research, and provide the
    resources and incentives that will drive more young scientists to
    commit to careers supporting continuing improvements in public health.
    This investment will also go directly into supporting jobs for U.S.
    citizens and residents and will continue to stimulate the economy.
        Many important drugs have been developed as a direct result of the
    basic knowledge gained from federally funded research, such as new
    therapies for breast cancer, the prevention of kidney transplant
    rejection, improved treatments for glaucoma, new drugs for depression,
    and the cholesterol lowering drugs known as statins that prevent
    125,000 deaths from heart attack each year. AIDS-related deaths have
    fallen by 73 percent since 1995 and the 5-year survival rate for
    childhood cancers rose to almost 80 percent in 2000 from under 60
    percent in the 1970s. NIH studies have indicated that adopting
    intensive lifestyle changes delayed onset of type 2 diabetes by 58
    percent and that progesterone therapy can reduce premature births by 30
    percent in women at risk.
        Historically, our past investment in basic biological research has
    led to innovative medicines that have virtually eliminated diphtheria,
    whooping cough, measles and polio in the United States. Eight out of
    ten children now survive leukemia. Death rates from heart disease and
    stroke have been reduced by half in the past 30 years. Molecularly
    targeted drugs such as GleevecTM to treat adult leukemia do
    not harm normal tissue and dramatically improve survival rates. NIH
    research has developed a class of drugs that slow the progression of
    symptoms of Alzheimer's disease. The robust past investment in the NIH
    has provided major gains in our knowledge of the human genome,
    resulting in the promise of pharmacogenetics and a reduction in adverse
    drug reactions that currently represent a major worldwide health
    concern.
        But unless NIH can maintain an adequate funding stream scientific
    opportunities will be delayed, lost, or forfeited to biomedical
    research opportunities in other countries and the human and economic
    cost will continue to impact all of us.
        Scientific inquiry leads to better medicine and there remain many
    challenges and opportunities that need to be addressed. Two issues
    specific to ASPET highlight the need for appropriate NIH funding
    levels.
      --The need to increase support for training and research in
            integrative/whole organ science. This will help to develop
            skilled scientists trained to understand how drugs act in whole
            animals, including human beings. Support for training and
            research in integrative whole organ sciences has been affirmed
            in the fiscal year 2002 Labor, Health and Human Services, and
            Education, and Related Agencies Appropriations Report (107-84).
            The Senate report supports ASPET recommendation that
            ``Increased support for research and training in whole systems
            pharmacology, physiology, toxicology, and other integrative
            biological systems that help to define the effects of therapy
            on disease and the overall function of the human body.'' These
            principles and recommendations are also affirmed in the FASEB
            Annual Consensus Conference Report on Federal Funding for
            Biomedical and Related Life Sciences Research for fiscal year
            2002.
      --The need to meet public health concerns over growing consumer use
            of botanical therapies and dietary supplements. These products
            have unsubstantiated scientific efficacy and may adversely
            impact the treatment of chronic diseases, create dangerous
            interactions with prescription drugs, and may cause serious
            side effects including death among some users. Through the NIH,
            research into the safety and efficacy of botanical products can
            be conducted in a rigorous and high-quality manner. Sound
            pharmacological studies will help determine the value of
            botanical preparations and the potential for their interactions
            with prescription drugs as well as chronic disease processes.
            This research will allow the FDA to review the available
            pharmacology and review valid evidence-based reviews to form a
            valid scientific foundation for regulating these products.
                                   conclusion
        NIH and the biomedical research enterprise face a critical moment.
    For the first time in 6 years, NIH has the potential to meet many of
    the more promising scientific opportunities that currently challenge
    medicine. Reversing the trends of the last half decade is only part of
    the solution. In order to help sustain scientific progress it is
    critical that NIH receive 7 percent to continue the progress made under
    the ARRA. A 7 percent increase for the NIH in fiscal year 2010 will
    permit the NIH to make greater strides to prevent, diagnose and treat
    disease, improving the health of our Nation and restoring the NIH to
    its role as a national treasure that attracts and retains the best and
    brightest to biomedical research.
                                     ______

      Prepared Statement of the American Society of Tropical Medicine and
                                    Hygiene
                                    overview
        The American Society of Tropical Medicine and Hygiene (ASTMH)
    appreciates the opportunity to submit written testimony to the Senate
    Labor, Health and Human, Services, and Education, and Related Agencies
    Appropriations Subcommittee. With more than 3,300 members, ASTMH is the
    world's largest professional membership organization dedicated to the
    prevention and control of tropical diseases.
        We respectfully request that the subcommittee provide the following
    allocations in the fiscal year 2010 Labor, Health and Human, Services,
    and Education, and Related Agencies Appropriations bill to support a
    comprehensive effort to enhance malaria control programming globally:
      --$18 million to the Centers for Disease and Control and Prevention
            (CDC) for malaria research, control, and program evaluation
            efforts with a $6 million set-aside for program monitoring and
            evaluation;
      --$32.19 billion to National Institutes of Health (NIH);
      --$5.07 billion to the National Institute of Allergy and Infectious
            Diseases (NIAID); and
      --$73.5 million to the Fogarty International Center (FIC).
        We very much appreciate the subcommittee's consideration of our
    views, and we stand ready to work with the subcommittee members and
    staff on these and other important global health matters.
                                     astmh
        ASTMH plays an integral and unique role in the advancement of the
    field of tropical medicine. Its mission is to promote global health by
    preventing and controlling tropical diseases through research and
    education. As such, ASTMH is the principal membership organization
    representing, educating, and supporting tropical medicine scientists,
    physicians, researchers, and other health professionals dedicated to
    the prevention and control of tropical diseases. Our members reside in
    46 States and the District of Columbia and work in a myriad of public,
    private, and nonprofit environments, including academia, the U.S.
    military, public institutions, Federal agencies, private practice, and
    industry.
        ASTMH's long and distinguished history goes back to the early 20th
    century. The current organization was formed in 1951 with the
    amalgamation of the National Malaria Society and the ASTMH. Over the
    years, the Society has counted many distinguished scientists among its
    members, including Nobel Laureates. ASTMH and its members continue to
    have a major impact on the tropical diseases and parasitology research
    carried out around the world.
        ASTMH aims to advance policies and programs that prevent and
    control those tropical diseases which particularly impact the global
    poor. ASTMH supports and encourages Congress to expand funding for--and
    commitments to--national and international malaria control initiatives.
    As part of this effort, ASTMH recently conducted an analysis of
    federally funded tropical medicine and disease programs and developed
    fiscal year 2010 funding requests based on this assessment.
                    tropical medicine and tropical diseases
        The term ``tropical medicine'' refers to the wide-ranging clinical,
    research, and educational efforts of physicians, scientists, and public
    health officials with a focus on the diagnosis, mitigation, prevention,
    and treatment of diseases prevalent in the areas of the world with a
    tropical climate. Most tropical diseases are located in either sub-
    Saharan Africa, parts of Asia (including the Indian subcontinent), or
    Central and South America. Many of the world's developing nations are
    located in these areas; thus tropical medicine tends to focus on
    diseases that impact the world's most impoverished individuals.
        The field of tropical medicine encompasses clinical work treating
    tropical diseases, work in public health and public policy to prevent
    and control tropical diseases, basic and applied research related to
    tropical diseases, and education of health professionals and the public
    regarding tropical diseases.
        Tropical diseases are caused by pathogens that are prevalent in
    areas of the world with a tropical climate. These diseases are caused
    by viruses, bacteria, and parasites which are spread through various
    mechanisms, including airborne routes, sexual contact, contaminated
    water and food, or an intermediary or ``vector''--frequently an insect
    (e.g. a mosquito)--that transmits a disease between humans in the
    process of feeding.
                                    malaria
        Malaria is a global emergency affecting mostly poor women and
    children; it is an acute and sometimes fatal disease caused by the
    single-celled Plasmodium parasite transmitted to humans by the female
    Anopheles mosquito.
        Malaria is an acute, often fatal disease caused by a single-celled
    parasite transmitted to humans by the female Anopheles mosquito.
    Malaria can cause anemia, jaundice, kidney failure, and death. Despite
    being treatable and preventable, malaria is one of the leading causes
    of death and disease worldwide. The World Health Organization (WHO)
    estimates there were 350 to 500 million malaria cases in 2000 and at
    least 1 million deaths from malaria, the vast majority of which were
    among young children in Africa. WHO estimates that one-half of the
    world's people are at risk for malaria, and that 109 countries are
    endemic for malaria. Malaria-related illness and mortality not only
    take a human toll, but also severely impact economic productivity and
    growth. The WHO has estimated that malaria reduces sub-Saharan Africa's
    economic growth by up to 1.3 percent per year.
        Fortunately, malaria can be both prevented and treated using four
    types of relatively low-cost interventions: (1) indoor residual
    spraying of insecticide on the walls of homes; (2) long-lasting
    insecticide-treated nets; (3) Artemisinin-based combination therapies;
    and (4) intermittent preventive therapy for pregnant women. However,
    limited resources preclude the provision of these interventions and
    treatments to all individuals and communities in need.
            requested malaria-related activities and funding levels
    CDC Malaria Efforts
        ASTMH calls upon Congress to fund a comprehensive approach to
    malaria control, including adequately funding the important
    contributions of CDC. CDC originally grew out of the WWII ``Malaria
    Control in War Areas'' program. Since its founding, the Atlanta-based
    agency has maintained a strong role in efforts to research and mitigate
    malaria. Although malaria has been eliminated as an endemic threat in
    the United States for more than 50 years, CDC remains on the cutting
    edge of global efforts to reduce the toll of this deadly disease.
        CDC efforts on malaria fall into three broad areas--prevention,
    treatment, and vaccines. The agency performs a wide range of basic
    research within these categories, such as--
      --investigation of the biology of host-parasite relationships;
      --immune response to malaria;
      --host genetic factors associated with malaria; parasite genetic
            diversity and drug resistance;
      --HIV and malaria interaction; the efficacy of insecticide-treated
            nets in preventing illness and deaths;
      --malaria and pregnancy;
      --public health strategies for improving access to antimalarial
            treatment and delaying the appearance of antimalarial drug
            resistance;
      --improved transmission reduction strategies; and
      --vaccine development and evaluation.
        Although endemic malaria has been eradicated in the United States,
    it remains one of world's leading causes of death and disease, and a
    significant proportion of CDC's malaria-focused work involves working
    in and with foreign countries to prevent the spread of malaria, and to
    assist in the treatment of those who have contracted the disease. CDC
    funding in fiscal year 2009 for global malarial activities is
    $9,396,000, which includes CDC's contribution to the $6.2 billion
    President's Malaria Initiative.
        CDC participates in several global efforts, including:
      --The President's Malaria Initiative (PMI).--The PMI is a $6.2
            billion, 9-year effort led by the U.S. Agency for International
            Development in conjunction with CDC and other Government
            agencies to lower the incidence of malaria in 15 targeted
            countries in sub-Saharan Africa by 50 percent.
      --Amazon Malaria Initiative.--This program works with countries in
            South America to combat the re-emergence of malaria in that
            part of the world.
      --West Africa Network Against Malaria During Pregnancy.--CDC works
            with countries in Francophone West Africa to encourage the use
            of intermittent preventive treatment with sulfadoxine-
            pyrimethamine (IPTp/SP) to prevent anemia and death in pregnant
            women and malaria-related low-birthweight in their newborns.
      --Preventing and Controlling Malaria During Pregnancy in Sub-Saharan
            Africa.--CDC works with many partners to prevent and control
            malaria among pregnant women and their newborns in sub-Saharan
            Africa.
      --International Red Cross and the Expanded Program for
            Immunizations.--CDC works with these groups to implement and
            evaluate the effectiveness of distributing ITNs during
            immunization campaigns and during routine vaccine visits.
        CDC collaborations support treatment and prevention policy change
    based on scientific findings; formulation of international
    recommendations through membership on WHO technical committees; and
    work with Ministries of Health and other local partners in malaria-
    endemic countries and regions to develop, implement, and evaluate
    malaria programs. In addition, CDC has provided direct staff support to
    the WHO; UNICEF; the Global Fund to Fight AIDS, Tuberculosis, and
    Malaria; and the World Bank--all stakeholders in the Roll Back Malaria
    Partnership.
                              nih malaria programs
        As the premier biomedical research agency for the United States and
    the world, the NIH and its Institutes and Centers play an essential
    role in the development of new anti-malarial drugs, better diagnostics,
    and an effective malaria vaccine. NIH estimates that its fiscal year
    2009 spending on malaria research will total $111 million while malaria
    vaccine efforts will receive $35 million. ASTMH urges that NIH malaria
    research portfolio and budget be increased by at least 6.6 percent in
    fiscal year 2010. To support a comprehensive effort to control malaria,
    ASTMH respectfully requests the following funding:
      --$32.9 billion to NIH;
      --$5.07 billion NIAID; and
      --$73.5 million to the FIC for training that supports U.S. efforts
            targeting malaria and other neglected tropical diseases.
    NIAID
        Malaria continues to be among the most daunting global public
    health challenges we face. A long-term investment is needed to achieve
    the drugs, diagnostics and research capacity needed to control malaria.
    NIAID, the lead Institute for malaria research, plays an important role
    in developing the drugs and vaccines needed to fight malaria. ASTMH
    urges the subcommittee to increase NIAID funding so that present
    malaria research efforts be maintained and new areas explored such as:
      --increasing fundamental understanding of the complex interactions
            among malaria parasites, the mosquito vectors responsible for
            their transmission and the human host;
      --developing new diagnostics, drugs, vaccines, and vector management
            approaches; and
      --enhancing both national and international research and research
            training infrastructure to meet malaria research needs.
    FIC
        Although biomedical research has provided major advances in the
    treatment and prevention of malaria, these benefits are often slow to
    reach the people who need them most. Highly effective anti-malarial
    drugs exist; when patients receive these drugs promptly, their lives
    can be saved. FIC plays a critical role in strengthening science and
    public health research institutions in low-income countries. By
    promoting applied health research in developing countries, the FIC can
    speed the implementation of new health interventions for malaria, TB,
    and neglected tropical diseases.
        The FIC works to strengthen research capacity in countries where
    populations are particularly vulnerable to threats posed by malaria and
    neglected tropical diseases. FIC efforts that strengthen the research
    workforce in-country--including collaborations with U.S.-supported
    global health programs--help to ensure the continuous improvement of
    programs, adapting them to local conditions. This maximizes the impact
    of U.S. investments and is critical to fighting malaria and other
    tropical diseases.
        FIC addresses global health challenges and supports the NIH mission
    through myriad activities, including:
      --collaborative research and capacity building projects relevant to
            low- and middle-income nations;
      --institutional training grants designed to enhance research capacity
            in the developing world, with an emphasis on institutional
            partnerships and networking;
      --the Forum for International Health, through which NIH staff share
            ideas and information on relevant programs and develop input
            from an international perspective on cross-cutting NIH
            initiatives;
      --the Multilateral Initiative on Malaria, which fosters international
            collaboration and co-operation in scientific research against
            malaria; and
      --the Disease Control Priorities Project, is a partnership supported
            by FIC, The Bill & Melinda Gates Foundation, the WHO, and the
            World Bank to develop recommendations on effective healthcare
            interventions for resource-poor settings.
        ASTMH urges the subcommittee to allocate additional resources to
    the FIC in fiscal year 2010 to increase these efforts, particularly as
    they address the control and treatment of malaria.
                                   conclusion
        Thank you for your attention to these important global health
    matters. We know you face many challenges in choosing funding
    priorities, and we hope you will provide the requested fiscal year 2010
    resources to those programs identified above. ASTMH appreciates the
    opportunity to share its views, and we thank you for your consideration
    of our requests.
                                     ______

              Prepared Statement of the American Thoracic Society
        The American Thoracic Society (ATS) is pleased to submit our
    recommendations for programs in the Labor, Health and Human Services,
    and Education, and Related Agencies Appropriations Subcommittee
    purview. ATS, founded in 1905, is an independently incorporated,
    international education and scientific society that focuses on
    respiratory and critical care medicine. With approximately 18,000
    members who help prevent and fight respiratory disease around the
    globe, through research, education, patient care and advocacy, ATS's
    long-range goal is to decrease morbidity and mortality from respiratory
    disorders and life-threatening acute illnesses.
                         respiratory disease in america
        Respiratory disease is a serious problem in America. Respiratory
    disease is the third leading cause of death, responsible for 1 of every
    7 deaths. Diseases effecting the lungs include chronic obstructive
    pulmonary disease, lung cancer, tuberculosis, influenza, sleep
    disordered breathing, pediatric lung disorders, occupational lung
    disease, sarcoidosis, asthma, and severe acute respiratory syndrome
    (SARS). The death rate due to chronic obstructive pulmonary disease
    (COPD) has doubled within the last 30 years and is still increasing,
    while the rates for the other three top causes of death (heart disease,
    cancer, and stroke) have decreased by more than 50 percent. The number
    of people with asthma in the United States has surged more than 150
    percent since 1980 and the root causes of the disease are still not
    fully known. Cystic fibrosis and pulmonary hypertension, which jointly
    affect nearly 150,000 people in the United States, have no cure.
                      national institutes of health (nih)
        The ATS deeply appreciates the $10 billion in supplemental funding
    provided for the NIH in the American Recovery and Reinvestment Act and
    the 3.2 percent increase provided through the omnibus fiscal year 2009
    appropriations legislation. This funding will allow the NIH to continue
    to fund, rather than curtail, groundbreaking research into diseases
    that affect millions of Americans like COPD, asthma, and tuberculosis.
    It is critical that this urgently needed reinvestment in biomedical
    research is reinforced through annual budget increases that include
    inflationary adjustments. We ask that this subcommittee provide a 7
    percent increase for NIH in fiscal year 2010 so that the institute can
    respond to biomedical research opportunities and public health needs.
        Despite the rising lung disease burden, lung disease research is
    underfunded. In fiscal year 2008, lung disease research represented
    just 20.4 percent of the National Heart Lung and Blood Institute's
    (NHLBI) budget. Although COPD is the fourth leading cause of death in
    the United States, research funding for the disease is a small fraction
    of the money that is invested for the other three leading causes of
    death. In order to stem the devastating effects of lung disease,
    research funding must continue to grow to sustain the medical
    breakthroughs made in recent years.
                   centers for disease control and prevention
        In order to ensure that health promotion and chronic disease
    prevention are given top priority in Federal funding, the ATS supports
    a funding level for the Centers for Disease Control and Prevention
    (CDC) that enables it to carry out its prevention mission, and ensure
    an adequate translation of new research into effective State and local
    public health programs. We also ask that the CDC budget be adjusted to
    reflect increased needs in chronic disease prevention, infectious
    disease control, including TB control to prevent the spread of drug-
    resistant TB, and occupational safety and health research and training.
    The ATS recommends a funding level of $8.6 billion for the CDC in
    fiscal year 2010. There are four lung diseases that illustrate the need
    for further investment in research and public health programs: COPD,
    pediatric lung disease, asthma and tuberculosis.
                                      copd
        COPD is the fourth leading cause of death in the United States and
    the third leading cause of death worldwide. Yet, the disease remains
    relatively unknown to most Americans. COPD is the term used to describe
    the airflow obstruction associated mainly with emphysema and chronic
    bronchitis and is a growing health problem. CDC estimates that 12
    million patients have COPD while an additional 12 million Americans are
    unaware that they have this life threatening disease.
        Today, COPD is treatable but not curable. Medical treatments exist
    to relieve symptoms and slow the progression of the disease.
    Fortunately, promising research is on the horizon for COPD patients.
    Despite these leads, the ATS feels that research resources committed to
    COPD are not commensurate with the impact the disease has on the United
    States and that more needs to be done to make Americans aware of COPD,
    its causes and symptoms. According to the NHLBI, COPD costs the U.S.
    economy an estimated $37 billion per year. We recommend that the
    subcommittee encourage NHLBI and other NIH Institutes to devote
    additional resources to finding improved treatments and a cure for
    COPD. The ATS commends the NHLBI for its leadership on educating the
    public about COPD through the National COPD Education and Prevention
    Program. As this initiative continues, we encourage the NHLBI to
    maintain its partnership with the patient and physician community.
        While additional resources are needed at NIH to conduct COPD
    research, CDC has a role to play as well. To address the increasing
    public health burden of COPD, the ATS encourages the CDC to create a
    COPD program at the Center for Chronic Disease Prevention and Health
    Promotion. We ask that the subcommittee provide an appropriation of $1
    million in fiscal year 2010 for this program. We are hopeful that the
    program will include development of a national COPD response plan,
    expansion of data collection efforts and creation of other public
    health interventions for COPD. The ATS also encourages the CDC to add
    COPD-based questions to future CDC health surveys, including the
    National Health and Nutrition Evaluation Survey (NHANES), the National
    Health Information Survey (NHIS) and the Behavioral Risk Factor
    Surveillance Survey (BRFSS).
                             pediatric lung disease
        Lung disease affects people of all ages. The ATS is pleased to
    report that infant death rates for various lung diseases have declined
    for the past 10 years. However, of the seven leading causes of infant
    mortality, four are lung diseases or have a lung disease component. In
    2005, lung diseases accounted for more than 19 percent of all infant
    deaths under 1 year of age. It is also widely believed that many of the
    precursors of adult respiratory disease start in childhood. The ATS
    encourages the NHLBI to continue with its research efforts to study
    lung development and pediatric lung diseases.
                                     asthma
        The ATS believes that the NIH and the CDC must play a leadership
    role in assisting individuals with asthma. National statistical
    estimates show that asthma is a growing problem in the United States.
    Approximately 22.2 million Americans currently have asthma, of which
    12.2 million had an asthma attack in 2005. African Americans have the
    highest asthma prevalence of any racial/ethnic group. The age-adjusted
    death rate for asthma in the African-American population is three times
    the rate in whites.
                                     sleep
        Sleep is an essential element of life, but we are only now
    beginning to understand its impact on human health. Several research
    studies demonstrate that sleep illnesses and sleep disordered breathing
    affect an estimated 50-70 million Americans. A recent study conduced by
    CDC found that roughly 10 percent of Americans had not gotten enough
    rest at any point in the previous 30 days. The public health impact of
    sleep illnesses and sleep disordered breathing is still being
    determined, but is known to include traffic accidents, lost work and
    school productivity, cardiovascular disease, obesity, mental health
    disorders, and other sleep-related comorbidities. Despite the increased
    need for study in this area, research on sleep and sleep-related
    disorders has been underfunded. The ATS recommends a funding level of
    $2 million in fiscal year 2010 to support activities related to sleep
    and sleep disorders at the CDC, including for the National Sleep
    Awareness Roundtable (NSART), surveillance activities, and public
    educational activities. The ATS also recommends an increase of funding
    for research on sleep disorders at the Nation Center for Sleep
    Disordered Research (NCSDR) at the NHLBI.
                                  tuberculosis
        Tuberculosis (TB) is the second leading global infectious disease
    killer, claiming 1.7 million lives each year. It is estimated that 9-14
    million Americans have latent tuberculosis. Drug-resistant TB poses a
    particular challenge to domestic TB control owing to the high costs of
    treatment and intensive health care resources required. Treatment costs
    for multidrug-resistant (MDR) TB range from $100,000 to $300,000, which
    can cause a significant strain on State public health budgets. The
    global TB pandemic and spread of drug resistant TB present a persistent
    public health threat to the United States.
        Despite low rates, persistent challenges to TB control in the
    United States remain. Specifically: (1) racial and ethnic minorities
    continue to suffer from TB more than majority populations; (2) foreign-
    born persons are adversely impacted; (3) sporadic outbreaks/clusters
    occur, outstripping local capacity; (4) continued emergence of drug
    resistance threaten our ability to control TB; and (5) there are
    critical needs for new tools for rapid and reliable diagnosis, short,
    safe and effective treatments, and vaccines.
        In recognition of the need to strengthen domestic TB control, the
    Congress passed the Comprehensive Tuberculosis Elimination Act (Public
    Law 110-392) in October, 2008. This historic legislation was based on
    the recommendations of the Institute of Medicine and revitalized
    programs at CDC and the NIH with the goal of putting the United States
    back on the path to eliminating TB. The new law authorizes an urgently
    needed reinvestment into new TB diagnostic, treatment and prevention
    tools. The ATS, in collaboration with Stop TB USA, recommends a funding
    level of $210 million in fiscal year 2010 for CDC's Division of TB
    Elimination, as authorized under the Comprehensive TB Elimination Act.
        The NIH has a prominent role to play in the elimination of
    tuberculosis through the development of new tools to fight the disease.
    We encourage the NIH to expand efforts, as requested under the
    Comprehensive TB Elimination Act, to develop new tools to reduce the
    rising global TB burden, including faster diagnostics that effectively
    identify TB in all populations, new drugs to shorten the treatment
    regimen for TB and combat drug resistance, and an effective vaccine.
               fogarty international center tb training programs
        The Fogarty International Center (FIC) at NIH provides training
    grants to U.S. universities to teach AIDS treatment and research
    techniques to international physicians and researchers. Because of the
    link between AIDS and TB infection, FIC has created supplemental TB
    training grants for these institutions to train international health
    care professionals in the area of TB treatment and research. These
    training grants should be expanded and offered to all institutions. The
    ATS recommends Congress provide $70 million for FIC in fiscal year
    2010, which would allow the expansion the TB training grant program
    from a supplemental grant to an open competition grant.
              researching and preventing occupational lung disease
        The National Institute of Occupational Safety and Health (NIOSH) is
    the sole Federal agency responsible for conducting research and making
    recommendations for the prevention of work-related diseases and injury.
    The ATS recommends that Congress provide $340.1 million in fiscal year
    2010 for NIOSH to expand or establish the following activities: the
    National Occupational Research Agenda (NORA); tracking systems for
    identifying and responding to hazardous exposures and risks in the
    workplace; emergency preparedness and response activities; and training
    medical professionals in the diagnosis and treatment of occupational
    illness and injury.
                                   conclusion
        Lung disease is a growing problem in the United States. It is this
    country's third leading cause of death. Lung disease and breathing
    problems are a leading killer of babies under the age of one year.
    Worldwide, tuberculosis is the second leading infectious disease
    killer. The level of support this subcommittee approves for lung
    disease programs should reflect the urgency illustrated by these
    numbers. The ATS appreciates the opportunity to submit this statement
    to the subcommittee.
                                     ______

    Prepared Statement of the Association of Women's Health, Obstetric and
                                Neonatal Nurses
        The Association of Women's Health, Obstetric and Neonatal Nurses
    (AWHONN) appreciates the opportunity to provide testimony on fiscal
    year 2010 appropriations for the Department of Health and Human
    Services (HHS).
        AWHONN is a nonprofit membership organization made up of 23,000
    nurses who care for mothers, their newborns, and women of all ages.
    AWHONN members are registered nurses, nurse practitioners, certified
    nurse-midwives, and clinical nurse specialists who work in hospitals,
    independent practices, universities and community clinics throughout
    the United States. Our mission is to promote the health of women and
    newborns.
        Nurses are typically the first and most consistent point of contact
    in the healthcare setting. Evidence suggests that they spend more time
    with patients--up to four times on average--than any other healthcare
    provider. As such, nurses have a unique perspective on the healthcare
    system and the public health programs and agencies funded under HHS.
        We thank the subcommittee for providing generous funding in past
    years and we are truly appreciative for the public health funding
    included in the American Recovery and Reinvestment Act of 2009.
    Recognizing the challenges the subcommittee will face in fiscal year
    2010 in reconciling various expenditures in the face of overall budget
    deficits, please find our funding recommendations for fiscal year 2010
    below.
              health resources and services administration (hrsa)
        As a member of the Friends of the Health Resources and Services
    Administration coalition, AWHONN recommends $8.5 billion for HRSA in
    fiscal year 2010.
        HRSA programs support health professions education, healthcare
    services for underserved populations, programs to address the special
    needs of mothers and children, and more. For several years, HRSA has
    suffered from relatively level funding. In light of these difficult
    economic times, support for the Nation's safety net system is
    especially critical.
        One of the most important aspects of HRSA's mission is to ensure a
    healthcare workforce that is sufficient to meet the needs of patients
    and communities.
    Nursing Workforce Development Programs, title VIII of the Public Health
            Service Act
        Along with the Nursing Community coalition, AWHONN recommends $215
    million for title VIII programs in fiscal year 2010. An adequate supply
    of nurses is essential to ensuring that all Americans receive quality
    healthcare. Title VIII programs help to address the Nation's ongoing
    nursing and nurse faculty shortage by providing scholarships and loan
    repayment programs to nursing students, recent graduates and nursing
    school faculty. Title VIII also provides grants to schools of nursing
    and health centers to foster greater diversity and improved retention
    rates in the nursing workforce.
    Maternal and Child Health (MCH) Block Grant, Title V of the Social
            Security Act
        AWHONN recommends $850 million for the MCH Block Grant in fiscal
    year 2010. The MCH Block Grant, the only Federal program of its kind,
    is devoted to improving the health of women and children. For more than
    70 years, the program has provided a source of flexible funding for
    States and territories to address their unique needs related to
    improving the health of mothers and children. Today, this program
    provides prenatal services to more than 2 million mothers--almost half
    of all mothers who give birth annually--and primary and preventive care
    to more than 17 million children, including almost 1 million children
    with special needs. Fully funding the MCH block grant will enable
    States to expand critical health services.
        We recommend $30 million for newborn screening activities, which
    are currently funded under the MCH block grant Special Projects of
    Regional and National Significance. Newborn screening is a vital public
    health activity used to identify and treat genetic, metabolic,
    hormonal, and functional conditions in newborns. Screening detects
    disorders in newborns that, if left untreated, can cause disability,
    mental retardation, serious illnesses or even death. While nearly all
    babies born in the United States undergo newborn screening for genetic
    birth defects, the number and quality of these tests vary from State to
    State.
                      national institutes of health (nih)
        AWHONN, along with others in the science advocacy community,
    support increased funding for NIH in fiscal year 2010. Scientific
    research done at the NIH is leading to better patient care. In fact,
    federally funded research is responsible for nearly every major medical
    advancement in the last 50 years. While AWHONN supports the NIH in its
    entirety, several Institutes are especially important to the
    advancement of nursing and the health of women and newborns.
    The Eunice Kennedy Shriver National Institute of Child Health and Human
            Development (NICHD)
        The rate of preterm birth has increased 20 percent since 1990. The
    NICHD supports critical research into the causes and treatments for
    preterm birth.
        AWHONN, along with the March of Dimes, recommends that Congress
    provide at least a 7 percent increase for NICHD in fiscal year 2010, a
    portion to be used to begin establishing transdisplinary research
    centers that focus on preterm birth. NICHD needs additional resources
    to expand research on the underlying causes of preterm birth taking
    into account the recommendations of the experts who participated in the
    Surgeon General's Conference on Preterm Birth in the summer of 2008.
    National Institute of Nursing Research (NINR)
        AWHONN, along with the American Nurses Association and the American
    Association of Colleges of Nursing, recommends $178 million for NINR in
    fiscal year 2010.
        NINR supports nurse-led research that contributes to advancing
    high-quality, evidence-based care across the lifespan. Research at NINR
    has targeted, among other topics, health disparities, risk reduction,
    chronic illnesses, and care for rural and underserved populations. NINR
    promotes a uniquely important nursing perspective, as there is no
    caregiver that interacts with patients more or is more trusted by
    patients than nursing professionals. There is no other body that funds
    important nursing research similarly in this country, and NINR research
    has contributed measurably to more efficient and effective healthcare
    as our Nation struggles to fill continuing staffing shortages and gaps
    in healthcare services.
                centers for disease control and prevention (cdc)
        The CDC is dedicated to protecting health and promoting quality of
    life through the prevention and control of disease, injury, and
    disability. While AWHONN supports the CDC in its entirety, several
    agencies and programs are especially important to the advancing the
    health of women and newborns.
    Safe Motherhood/Infant Health
        The Safe Motherhood/Infant Health program works to promote infant
    and reproductive health. AWHONN is especially concerned with issues
    associated with prematurity. Preterm birth is the leading cause of
    neonatal death in the United States. In 2006, more than half a million
    babies--1 in 8 babies--were born prematurely in the United States.
        In 2005, AWHONN launched its Late Preterm Initiative to address the
    special needs of infants born between 34 and 36 completed weeks of
    gestation. While many late preterm infants may appear healthy at birth,
    they are at risk for prematurity-related complications, increased
    morbidity and mortality and have an increased rate of rehospitalization
    in the first month of life.
        Currently, the CDC is partnering with a number of universities and
    organizations to support research related to preterm birth and the
    reasons for disparities between racial and ethnic groups. AWHONN
    recommends a $6 million increase in the preterm birth line fiscal year
    2010. This funding will allow the CDC to expand epidemiological work to
    evaluate the social, biological, and medical factors associated with
    preterm birth as authorized in the PREEMIE Act of 2006 (Public Law 109-
    450).
    National Center on Health Statistics (NCHS)
        NCHS is the Nation's principal health statistics agency, providing
    critical data on all aspects of the U.S. healthcare system. The agency
    provides data on healthcare trends, information that is essential for
    public health planning. However, current funding levels are threatening
    the collection of vital information, especially complete data on
    maternity and infant health status.
        AWHONN, along with the Friends of NCHS, recommends at least $137.5
    million for NCHS in fiscal year 2010. Additionally, we urge Congress to
    allocate $15 million bolus funding to support States and territories as
    they implement the 2003 birth certificates and electronic systems to
    collect these data.
                                     ______

               Prepared Statement of the Animal Welfare Institute
        The Animal Welfare Institute (AWI) respectfully requests that the
    subcommittee include the following report language regarding the
    funding of research involving the use of dogs and/or cats:

        None of these funds shall be used for the purchase of, or research
    on, dogs or cats obtained from those USDA licensed Class B dealers who
    acquire dogs or cats from third parties (i.e., individuals, dealers,
    breeders, and animal pounds) and resell them.

        In response to the request included in last year's appropriation
    bill, the National Academy of Sciences (NAS) established a committee in
    the summer of 2008 to assess if there is a scientific rationale for
    relying on dogs and cats obtained from United States Department of
    Agriculture (USDA) licensed Class B dealers. Information on the
    Committee on Scientific and Humane Issues in the Use of Random-source
    Dogs and Cats for Research (ILAR-K-08-01-A) can be found at: http://
    www8.nationalacademies.org/cp/projectview.aspx?key=48974. The results
    of its deliberations are expected to be public later this month.
        Based on our review of the data submitted to the NAS Committee, the
    presentations given during those portions of the meetings that were
    open to public, and our own extensive experience regarding Class B-
    licensed dealers, we anticipate findings in keeping with the proposed
    report language above.
        According to USDA, of the nearly 95,000 total dogs and cats used in
    research, 2,863 dogs and 267 cats were supplied by random source
    dealers during fiscal year 2007. There are a mere 10 Class B dealers
    currently licensed by USDA and selling live random source dogs and cats
    for experimentation. One other dealer is presently under a 5-year
    license suspension. These dealers are notorious for selling to
    laboratories animals who have been acquired illegally and for their
    widespread failure to comply with other minimum requirements under the
    Animal Welfare Act. In fact, at this time, half of the remaining 10
    dealers are under investigation by USDA for apparent violations of the
    Animal Welfare Act (AWA), and USDA is pursuing seven separate
    investigations regarding apparent supply violations identified during
    tracebacks conducted of dealer records.
        Data from USDA inspection reports reveal myriad problems with
    licensed Class B dealers (we can supply copies of these inspection
    reports if they are of interest): Needed veterinary care is lacking for
    many random source animals. Hookworm and mange are a widespread problem
    as is heartworm, particularly in the South. An Ohio dealer had a dog
    with mange on his head, around the eyes, ears and neck. Another dog had
    enlarged pupils and bulging eyes, and a third had dried loose dark
    stool. An Indiana dealer was cited by USDA for dogs suffering from
    ``loose stool with some blood,'' ``loose stool with a drop of blood,''
    ``infected or irritated eye,'' ``mange-like lesions,'' ``ring-worm like
    lesions,'' ``sore on left carpus which was red and warm to the touch,''
    and an animal with ``a bite wound to the right front foot.'' At another
    inspection, this dealer had two animals who were limping; one had a
    large tumor on his foot. A third animal had a bite laceration on his
    face. Another record notes a chronic cough in an underweight dog and a
    dog with a purulent discharge from his nose. In most cases there is no
    record of any veterinary care, and after being cited by USDA
    inspectors, given the poor status of the animals, they are typically
    killed. An Illinois dealer was cited by USDA for ``euthanizing dogs
    with truck exhaust and tying sick dogs out at the corner of the
    property where they would die.'' Later he shifted to use of an electric
    current administered via clips.
        Research institutions may reject animals delivered by a dealer
    because of the poor condition of the dogs and cats, leaving them to be
    hauled from location to location in search of a taker. If not, the
    animal may be taken back and left to die or may simply be shot. Some at
    research institutions have let USDA know of their concerns. One such
    email identified a cat ``in very poor condition: cache[c]tic, severely
    matted hair coat and a severe case of ear mites.'' It went on to note:

        ``Many of the cats that we receive are wild or are almost wild. I
    do not understand where these cats come from and how they are examined
    for health certificates. I thought the animals had to come from someone
    who had raised and bred the animals on their property or from a
    specific shelter.''

        The conditions for housing, feeding, and care can be problematic as
    well. An Ohio dealer was cited by USDA inspectors for contaminated
    straw, wet with urine and excessive feces. Excessive flies. Water
    receptacles contaminated with black and green algae--a thick layer. A
    dealer in Indiana had dogs unable to avoid contact with excreta.
    Another dealer's inspection report notes, ``Some 70-75 percent dogs
    have water and bread and little bits of dog food floating in water.
    There were some dogs that had only bread and water. Some had dog food
    floating in water. Most of dogs had not eaten the watery food blend.
    About 70 percent of the total dogs had nonpotable water. Water was
    mixed with bread and dog food and sitting in the direct sun.''
        In addition, there are widespread problems with record-keeping and
    acquiring animals from illegal sources. Further, dealers commonly
    network with each other; that is, animals are sold from buncher (an
    unlicensed dealer) to dealer to another dealer before being sold for
    research. Also, typically, the buncher is immune from prosecution until
    he is caught by USDA and warned not to sell more than 25 animals in a
    year without a license again. Then he drops down to selling fewer
    animals so he is exempt from licensure, he sells some of the animals
    using the name of someone else he knows, or he steps forward and gets
    licensed for a while, makes a lot of money and then when USDA appears
    to be catching up with him, he turns in his license.
        One example is the case of Clayton McDowell, a buncher with hunting
    dog kennels who didn't let the fact that he had no license stop him
    from selling 60 dogs to a USDA licensed Class B dealer in Illinois.
    According to USDA, he ``knew about USDA licensing requirements. He
    stated he would quit selling dogs to B dealers. He stated there was too
    much hassle with identification, record keeping.'' McDowell received a
    Letter of Warning from USDA, and he addressed the matter by getting
    licensed. Ultimately, he decided to quit operating as a licensed Class
    B dealer, though he continued selling hunting dogs, claiming he would
    only sell the dogs retail for hunting purposes.
        Then there's a Kentucky dealer cited by a USDA inspector who
    repeatedly failed to include essential details on the acquisition
    sheets, such as the seller's address, driver's license number, and
    vehicle tag number. He was found to have failed to collect this
    information on 3 different dates regarding 13 animals. And a Michigan
    dealer was cited for receiving stray cats from the city of Howard City.
    The city has no pound, but the licensed dealer was willing to step in
    and collect cats. An Illinois dealer was cited on at least three
    separate occasions for his failure to maintain complete records.
        A veterinarian at a research facility expressed concern in an email
    to USDA that the animals it received from a dealer appeared to be
    ``companion animals.'' A neutered male Airedale, an intact male
    Weimeriner and a male chocolate Labrador all were affectionate and
    obeyed commands. Similarly, the cats received by the facility were
    ``some of the most obedient and affectionate cats that we ever met.''
        Another common pattern is for individuals to pass the business on
    to other members of the family after carefully showing them the ropes.
    Sometimes a former employee of a dealer, who has also learned how to
    work the system, may go off on his own and get licensed as well. Though
    it's not a formal program, in essence some dealers offer an
    apprenticeship.
        Brothers living in Missouri ran their licensed Class B dealer
    operation as a team, then one of them retired and the other's wife
    joined him in running the business. USDA finally caught up with the
    pair, and they were charged with a laundry list of violations,
    including failure to maintain records that fully and correctly disclose
    the identities and other required information of the persons from whom
    dogs were acquired on 51 separate occasions, including one incident
    that pertained to 43 dogs. Further, they were charged with failing to
    provide complete certifications on seven separate occasions, including
    one that pertained to 195 dogs. The husband died before the case was
    resolved and though the wife was fined $107,250, the judge suspended
    $100,000 of it. The story doesn't end here. The couple's son and
    daughter-in-law, after helping mom close down her business, set up
    their own Class B dealer operation.
        During a House Agriculture Subcommittee hearing held back in 1996,
    then Assistant Secretary of Agriculture Michael Dunn described his
    frustration with random source dealers: ``Every time we develop a new
    way to look for something, they develop a new way to hide it.'' An
    insurmountable hurdle for USDA is that the AWA allows anyone who claims
    to have bred and raised an animal to profit by selling the animal to a
    random source dealer--and how can USDA be expected to disprove it? In
    addition, with animals transported back and forth across the country,
    how on earth is USDA supposed to keep up with the movement of animals?
    USDA has spent years inspecting random source dealers four times a year
    instead of once a year as is done with all other licensees and
    registrants under the AWA. In the meantime, unlike any other licensees
    covered under the AWA, this one group of licensees--Class B dealers
    selling dogs and cats for research--have a long-standing problem
    maintaining complete and accurate records.
        The Animal Welfare Act was passed in 1966 to address the illegal
    supply of dogs and cats to laboratories, and here we are 43 years
    later, and these problems are still widespread. What has changed
    significantly over this lengthy period of time is the availability of
    animals from sources other than random source dealers. Given the
    problems inherent in the use of licensed Class B dealers, researchers
    have increasingly and successfully shifted to acquiring most of their
    dogs and cats from licensed Class A breeders--and by using these
    dealers instead, the researchers will receive animals who have been
    raised under controlled conditions, and the health and vaccination
    status and the genetic background on each individual animal will be
    known. In addition, some dogs and cats are being bred for
    experimentation at registered research facilities, and in some cases,
    inexpensive random type animals are purchased directly from animal
    pounds.
        NIH has told this subcommittee that it is ``committed to ensuring
    the appropriate care and use of animals in research.'' However, NIH has
    left the decision of whether or not to buy dogs and cats from random
    source dealers ``to the local level on the basis of scientific need.''
    NIH defends the use of licensed Class B dealers, arguing that these
    dealers are needed to obtain ``animals that may not be available from
    other sources, such as genetically diverse, older, or larger animals.''
    In fact, in the rare circumstance that a researcher asserts the need
    for such animals, they can be obtained directly from pounds, as noted
    previously.
        The distinction between nonpurpose-bred animals from pounds versus
    licensed Class B dealers must be made. By using licensed Class B
    dealers (middlemen) instead of pounds, researchers are contributing to
    the problem. In their search to fill researchers' demands for
    ``genetically diverse, older or larger animals,'' random source dealers
    and their suppliers may be stealing pets from backyards and farms or
    they may be acquiring them from individuals who did not breed and raise
    them as required by the AWA.
        All animals used in research should be obtained from lawful
    sources. Taxpayer dollars, in the form of NIH extramural grants, must
    not continue to fund research using dogs and cats from dealers whose
    modus operandi is illegal acquisition of animals, fraudulent or
    incomplete records, and other illicit activities. Proper oversight of
    NIH's dispersal of extramural grants to those engaged in research using
    dogs and/or cats is urgently needed.
                                     ______

           Prepared Statement of Big Brothers Big Sisters of America
        Big Brothers Big Sisters of America (BBBSA) supports $17 million in
    fiscal year 2010 for the Department of Education's Mentoring programs,
    $50 million for the Mentoring Children of Prisoners program and $50
    million for the Volunteer Generation Fund.
        Chairman Harkin and Ranking Member Cochran, thank you for the
    opportunity to submit this testimony for the subcommittee's record.
        BBBSA is the Nation's oldest and largest mentoring organization. We
    have grown over the last 105 years to serve more than 250,000 at-risk
    youth in communities across the Nation. Our 392 agencies are located in
    all 50 States, Guam, and Puerto Rico. We match at-risk youth with a
    caring adult in a one-to-one mentoring relationship. These matches make
    a significant difference in the life of a child and are the foundation
    for developing the full potential of boys and girls as they grow to
    become competent, confident, and caring men and women. BBBSA offers an
    array of programs and services that focus on promoting positive youth
    development, helping each child discover his or her full potential.
        With 17 million at-risk children growing up in America, the need
    for a proven strategy to reverse the statistics and to support their
    successful development has never been more critical. We believe that
    BBBS mentoring provides a significant return on investment,
    particularly compared to the consequences of social and educational
    failure. According to Independent Sector, the value of volunteer work
    was estimated at $20.25 per hour in 2008. Last year, our Bigs
    contributed more than 13 million volunteer hours at an estimated value
    of $676 million.
        BBBSA original, core program model is its community-based match.
    Bigs are matched with Littles referred to the program by a parent, and
    typically a match will spend about 3 hours per week together.
    Professional case-management staff at each local agency guide Bigs and
    provide them with the support necessary to ensure a healthy and lasting
    relationship with their Littles. It is through the relationship with
    these committed adults that at-risk children can to begin to gain their
    own sense of self-confidence and develop healthy aspirations for the
    future.
        Research has shown that BBBS mentoring works as a strategy to
    support at-risk youth. In 1995, Public/Private Ventures released its
    landmark impact study, which found that children matched with a Big
    Brother or Big Sister were:
      --46 percent less likely to begin using illegal drugs;
      --27 percent less likely to begin using alcohol;
      --52 percent less likely to skip school;
      --37 percent less likely to skip a class;
      --more confident of their performance in schoolwork; and
      --getting along better with their families.
             school-based mentoring (mentoring for success grants)
        Our mentoring programs have grown exponentially over the last 10
    years. A major source of this growth is the expansion of BBBSA school-
    based program model. Locating our service in schools has offered a
    strong complement to the traditional community-based approach and has
    resulted in a significant increase in volunteer recruitment. Further,
    because children are referred by teachers, it connects the positive
    impact of the BBBSA relationships directly with the educational
    enrichment for each matched child.
        The President's fiscal year 2010 budget outline for the Department
    of Education has recommended that the Department's mentoring program be
    eliminated. This recommendation was made in follow-up to a Federal
    study examining outcomes for school-based mentoring. The findings of
    the study are generating important and welcome dialogue. BBBSA
    appreciates the focus on quality programs and has reached out to the
    administration to offer our input in finding the most effective way to
    achieve positive outcomes for children.
        We believe that well-run school based mentoring programs can and do
    have real impact. We have both the local and national evidence to prove
    this, including a more recent evaluation by P/PV. In fact, findings
    from the P/PV study led us to adopt significant changes to the way we
    run our own school-based programs in order to ensure longer and
    stronger matches that lead to concrete and measurable outcomes for the
    young people we serve. As a learning organization, we take seriously
    our responsibility to respond to research and continually improve our
    service delivery.
        In 2003, with support from Atlantic Philanthropies, BBBSA began a
    comprehensive study of our school-based mentoring program and evaluated
    impacts on randomly selected mentored youth compared to nonmentored
    youth in a control group. The scope of the study paralleled the BBBS
    Impact Study of Community-Based Mentoring conducted by P/PV in the
    1990s and was the first nationwide, randomized study of school-based
    mentoring ever undertaken.
        Among the findings:
      --Three factors lead to better outcomes--
        --Socio-emotional match activities;
        --Matches that met more often and for longer periods; and
        --A strong school environment and involvement by teachers and
                principals;
      --School-based mentoring has positive academic outcomes during the
            first year of the match, including higher grades, higher
            feelings of academic competence, greater number of assignments
            completed, fewer serious school infractions, and less skipping
            of school;
      --But largely because so many matches did not continue into the
            second year, these outcomes were for the most part not
            sustained in the second year;
      --Training, supervision, and school support are critical in fostering
            stronger and longer relationships; and
      --The cost of school-based mentoring is only slightly less than
            community-based mentoring.
        The challenge was clear: longer matches and closer relationships
    meant stronger impacts and so how were we going to create longer
    matches and their corresponding increased, longer-lasting outcomes? The
    recommendations, coming out of the Study, of our internal School-Based
    Mentoring Task Force were:
      --Start matches as early in the school year as possible;
      --Ensure that volunteers provide at least one school year of
            mentoring;
      --Build programs in feeder schools to sustain matches and provide
            youth with consistency through school transitions;
      --Select supportive schools for program involvement and continually
            foster these partnerships;
      --Explore ways to bridge the summer gap such as taking school-based
            mentoring out of the school year and increasing match contacts
            and treating school-based mentoring as a year-round program
            with strong match support;
      --Develop indices of match length that reflect the summer break and,
            in this way, are more sensitive predictors of impacts; and
      --Explore more ways to provide volunteers (particularly young
            volunteers) with the support and ongoing training they need to
            create high-quality, effective mentoring relationships.
        While BBBSA supports the administration's position of only funding
    effective programs going forward, we have proposed partnering with the
    Department of Education to ensure that existing grantees do not have to
    prematurely close any current mentoring relationships. We understand
    that the cost of honoring the last class of grants which were awarded
    in fiscal year 2008 would require Congress to provide $17 million for
    the program in fiscal year 2010.
                    amachi (mentoring children of prisoners)
        An estimated 2.4 million children have an incarcerated parent--and
    BBBS' Amachi program addresses this critical need. The goal of Amachi
    is to demonstrate that the best way to stop the vicious cycle of
    substance abuse, delinquency, and incarceration among children of
    incarcerated parents is to give the children what they need the most--a
    supportive and stable adult who will help them discover their own
    strengths, abilities, and resistance skills. Volunteers for the program
    are recruited through their congregations and matched with at-risk
    children and youth, spending time each week with the child to gradually
    build a supportive relationship. Research has shown that children and
    youth of incarcerated parents are at higher risk of child abuse,
    neglect, illiteracy, drug and alcohol abuse, crime, violence, and
    premature death than are their peers. A BBBS mentor in the life of an
    at-risk child can dramatically reduce a child's chance of falling prey
    to these risks. We respectfully request level funding for the
    ``Mentoring Children of Prisoners'' program in fiscal year 2010.
          volunteer generation fund (corporation for national service)
        In the wake of President-elect Obama's ``call to service'' in
    January, also known as National Mentoring Month, BBBSA saw a
    significant increase in volunteer applications. As the economic crisis
    deepens, these Big Brothers and Big Sisters will be helping to meet the
    critical demand our disadvantaged youth have for friendship, especially
    during these challenging times. There is an interest among Americans to
    serve the community and BBBSA is anxious to harness this hope. The
    bipartisan citizen service legislation signed in to law by President
    Obama on April 21 will expand opportunities for citizens to serve, will
    direct this service toward the Nation's most urgent challenges, and
    provides Congress the change to invest in new and innovative solutions
    to our most persistent social problems. In particular, BBBSA
    respectfully requests that $50 million for the Volunteer Generation
    Fund in fiscal year 2010 to spur innovation in volunteer recruitment
    and management.
        As we all work to change how our children grow up in America, BBBSA
    is your proud partner.
                                     ______

              Letter From the Brain Injury Association of America
                                                           May 6, 2009.
    Hon. Tom Harkin,
    Chairman, Senate Appropriations Subcommittee on Labor, Health and Human
            Services, and Education, and Related Agencies, Washington, DC.
    Hon. Thad Cochran,
    Ranking Member, Senate Appropriations Subcommittee on Labor, Health and
            Human Services, and Education, and Related Agencies,
            Washington, DC.
        Dear Mr. Chairman Harkin and Ranking Member Cochran: Thank you for
    the opportunity to submit this written testimony with regard to the
    fiscal year 2010 Labor, Health and Human Services, and Education, and
    Related Agencies appropriations bill. My testimony is on behalf of the
    Brain Injury Association of America (BIAA), our national network of
    State affiliates, and hundreds of local chapters and support groups
    from across the country.
        A traumatic brain injury (TBI) is a blow or a jolt to the head that
    temporarily or permanently disrupts brain function--i.e., who we are
    and how we think, act, and feel. In the civilian population alone every
    year, more than 1.5 million people sustain brain injuries from falls,
    car crashes, assaults and contact sports. Males are more likely than
    females to sustain brain injuries. Children, teens, and seniors are at
    greatest risk.
        And now we are seeing an increasing number of servicemembers
    returning from the conflicts in Iraq and Afghanistan with TBI, which
    has been termed one of the signature injuries of the war. A recent
    study conducted by the RAND Corporation found that 320,000 troops, or
    19 percent of all service members, returning from Operations Enduring
    Freedom and Iraqi Freedom may have experienced a TBI during deployment.
    Many of these returning servicemembers are undiagnosed or misdiagnosed
    and subsequently they and their families will look to community and
    local resources for information to better understand TBI and to obtain
    vital support services to facilitate successful reintegration into the
    community.
        For the past 12 years Congress has provided minimal funding through
    the Health Resources and Services Administration (HRSA) Federal TBI
    Program to assist States in developing services and systems to help
    individuals with a range of service and family support needs following
    their loved one's TBI. Similarly, the grants to State Protection and
    Advocacy Systems to assist individuals with traumatic brain injuries in
    accessing services through education, legal, and advocacy remedies are
    woefully underfunded. Rehabilitation, community support, and long-term
    care systems are still developing in many States, while stretched to
    capacity in others. Additional numbers of individuals with TBI as the
    result of war-related injuries only adds more stress to these
    inadequately funded systems.
        BIAA respectfully urges you to provide States with the resources
    they need to address both the civilian and military populations who
    look to them for much needed support in order to live and work in their
    communities.
        With broader regard to all of the programs authorized through the
    TBI Act, BIAA specifically requests:
      --$11 million for the Centers for Disease Control and Prevention
            (CDC) TBI Registries and Surveillance, Prevention and National
            Public Education/Awareness;
      --$20 million for the HRSA Federal TBI State Grant Program; and
      --$6 million for the HRSA Federal TBI Protection & Advocacy (P&A)
            Systems Grant Program.
        The TBI Act Amendments of 2008, authorizes the Department of Health
    and Human Services, HRSA to award grants to (1) States, American Indian
    Consortia, and territories to improve access to service delivery and to
    (2) State P&A Systems to expand advocacy services to include
    individuals with TBI. For the past 12 years the HRSA Federal TBI State
    Grant Program has supported State efforts to address the needs of
    persons with TBI and their families and to expand and improve services
    to underserved and unserved populations including children and youth;
    veterans and returning troops; and individuals with co-occurring
    conditions
        In fiscal year 2009, HRSA reduced the number of State grant awards
    to 15, in order to increase each monetary award from $118,000 to
    $250,000. This means that many States that had participated in the
    program in past years have now been forced to close down their
    operations, leaving many unable to access TBI care.
        Increasing the program to $20 million will provide funding
    necessary for each State including the District of Columbia, the
    American Indian Consortium to sustain and expand State service
    delivery; and to expand the use of the grant funds to pay for such
    services as Information & Referral (I&R), service coordination and
    other necessary services and supports identified by the State.
        Similarly, the HRSA TBI P&A Program currently provides funding to
    all State P&A systems for purposes of protecting the legal and human
    rights of individuals with TBI. State P&As provide a wide range of
    activities including training in self-advocacy, outreach, I&R, and
    legal assistance to people residing in nursing homes, to returning
    military seeking veterans benefits, and students who need educational
    services.
        Effective Protection and Advocacy services for people with a TBI
    leads to reduced government expenditures and increased productivity,
    independence, and community integration. However, advocates must
    possess specialized skills, and their work is often time-intensive. A
    $6 million appropriation would trigger a formula that would ensure that
    each P&A can provide a significant PATBI program with appropriate staff
    time and expertise.
        Funding for the TBI Model Systems is urgently needed to ensure that
    the Nation's valuable TBI research capacity is not diminished, and to
    maintain and build upon the 16 TBI Model Systems research centers
    around the country.
        The TBI Model Systems of Care program represents an already
    existing vital national network of expertise and research in the field
    of TBI, and weakening this program would have resounding effects on
    both military and civilian populations. The TBI Model Systems are the
    only source of nonproprietary longitudinal data on what happens to
    people with TBI. They are a key source of evidence-based medicine, and
    serve as a ``proving ground'' for future researchers.
        In order to make this program more comprehensive, Congress should
    provide $13.3 million in fiscal year 2010 funding for the National
    Institute on Disability and Rehabilitation Research's TBI Model Systems
    of Care Program, in order to add four new centers and two collaborative
    research projects. In addition, given the national importance of this
    research program, the TBI Model Systems of Care program should receive
    ``line-item'' status within the broader NIDRR budget.
        We ask that you consider favorably these requests for the HRSA
    Federal TBI Program, NIDRR TBI Model Systems Program, and for CDC to
    gather needed data, shepherd public awareness, education, and
    prevention programs; as well as the sustain and bolster TBI Model
    Systems that conduct vital research.
                Sincerely,
                                              Susan H. Connors,
                                                         President/CEO.
                                     ______

      Prepared Statement of the Crohn's and Colitis Foundation of America
        Mr. Chairman and members of the subcommittee, thank you for the
    opportunity to submit testimony on behalf of the 1.4 million Americans
    living with Crohn's disease and ulcerative colitis. My name is Gary
    Sinderbrand and I have the privilege of serving as the Chairman of the
    National Board of Trustees for the Crohn's and Colitis Foundation of
    America (CCFA). CCFA is the Nation's oldest and largest voluntary
    organization dedicated to finding a cure for Crohn's disease and
    ulcerative colitis--collectively known as inflammatory bowel diseases
    (IBD).
        Let me say at the outset how appreciative we are for the leadership
    this subcommittee has provided in advancing funding for the National
    Institutes of Health (NIH). Hope for a better future for our patients
    lies in biomedical research and we are grateful for the recent
    investments that you have made in this critical area.
        Mr. Chairman, Crohn's disease and ulcerative colitis are
    devastating inflammatory disorders of the digestive tract that cause
    severe abdominal pain, fever and intestinal bleeding. Complications
    include arthritis, osteoporosis, anemia, liver disease and colorectal
    cancer. We do not know their cause, and there is no medical cure. They
    represent the major cause of morbidity from digestive diseases and
    forever alter the lives of the people they afflict--particularly
    children. I know, because I am the father of a child living with
    Crohn's disease.
        Seven years ago, during my daughter, Alexandra's sophomore year in
    college, she was taken to the ER for what was initially thought to be
    acute appendicitis. After a series of tests, my wife and I received a
    call from the attending GI who stated coldly: Your daughter has Crohn's
    disease, there is no cure and she will be on medication the rest of her
    life. The news froze us in our tracks. How could our vibrant, beautiful
    little girl be stricken with a disease that was incurable and has
    ruined the lives of countless thousands of people?
        Over the next several months, Alexandra fluctuated between good
    days and bad. Bad days would bring on debilitating flares which would
    rack her body with pain and fever as her system sought equilibrium. Our
    hearts were filled with sorrow as we realized how we were so incapable
    of protecting our child.
        Her doctor was trying increasingly aggressive therapies to bring
    the flares under control.
        Asacol, Steroids, Mercaptipurine, Methotrexate, and finally
    Remicade. Each treatment came with its own set of side effects and
    risks. Every time A would call from school, my heart would jump before
    I picked up the call in fear of hearing that my child was in pain as
    the flares had returned. Ironically, the worst call came from one of
    her friends to report that A was back in the ER and being evaluated by
    a GI surgeon to determine if an emergency procedure was needed to clear
    an intestinal blockage that was caused by the disease. Several hours
    later, a brilliant surgeon at the University of Chicago, removed over a
    foot of diseased tissue from her intestine. The surgery saved her life,
    but did not cure her. We continue to live every day knowing that the
    disease could flare at any time with devastating consequences.
        From the point of hearing the news, I refused to accept the fact
    that this disease could not be cured. As I studied all the relevant
    data I could find, I reached out to the organization that seemed to be
    repeatedly mentioned, The CCFA. This organization is leading the fight
    in research, education and support on behalf of the 1.4 million
    Americans that suffer from these illnesses.
        I made a pest of myself at the national office seeking knowledge
    about how the fight was being staged. The more I learned the more I
    believed that we could do better. I was invited to join the national
    board and 6 years later, I have the privilege of leading an
    extraordinary staff of professionals and a network of volunteers across
    our entire country.
        We are making dramatic progress that is the result of the
    scientific excellence of our funded researchers and our volunteer
    scientific leadership as well as the rapid advancement of available
    technology. It is now not ``if'' we will cure IBD, but ``when.''
        Mr. Chairman, I will focus the remainder of my testimony on our
    appropriations recommendations for fiscal year 2010.
                      recommendations for fiscal year 2010
    NIH
        Throughout its 40-year history, CCFA has forged remarkably
    successful research partnerships with the NIH, particularly the
    National Institute of Diabetes and Digestive and Kidney Diseases
    (NIDDK), which sponsors the majority of IBD research, and the National
    Institute of Allergy and Infectious Diseases (NIAID). CCFA provides
    crucial ``seed-funding'' to researchers, helping investigators gather
    preliminary findings, which in turn enables them to pursue advanced IBD
    research projects through the NIH. This approach led to the
    identification of the first gene associated with Crohn's--a landmark
    breakthrough in understanding this disease.
        To further accelerate genetic research and advance understanding of
    IBD, NIDDK issued a research solicitation to establish an IBD Genetics
    Consortium approximately 8 years ago. This effort was informed by
    recommendations from external experts. Funding for the Consortium's six
    centers began in 2002, and intensive data and sample collection,
    genetic analysis, and recruitment of new patients and their families
    have been under way. In 2006, the Consortium published the major
    discovery of a new IBD gene. Some sequence variations in this gene,
    called IL23R, were found to increase susceptibility to IBD, while
    another variant actually confers protection. This gene was known
    previously to be involved in inflammation, and its newly discovered
    association with IBD may lead to the development of better therapies
    for IBD. In recognition of the success of the Consortium's large-scale
    collaborative effort, NIDDK decided to continue support for the program
    beyond its initial 5-year period which was slated to end in fiscal year
    2007.
        Renewed funding in fiscal year 2008 has enabled the Consortium to
    continue its genetic studies and recruit additional patients and
    relatives (as well as subjects without IBD for comparison). This
    expansion will facilitate the identification of additional predisposing
    genes and enable genetic analyses of certain patient subgroups, such as
    those from minority populations or those who experience an early onset
    form of IBD. These findings may then be used to pursue genetically
    based diagnostic tests that allow for earlier diagnosis and treatment
    intervention. In addition, the data can be used to identify new
    molecular targets for therapeutic development that are specifically
    targeted to a unique subset of patients.
        Mr. Chairman, we are grateful for the leadership of Dr. Stephen
    James, Director of NIDDK's Division of Digestive Diseases and
    Nutrition, for pursuing this and other opportunities in IBD research
    aggressively. Fortunately, the field of IBD is widely viewed within the
    scientific community as one of tremendous potential. CCFA's scientific
    leaders, with significant involvement from NIDDK, have developed an
    ambitious research agenda entitled ``Challenges in Inflammatory Bowel
    Diseases'' that seeks to address many opportunities that currently
    exist. We look forward to working with NIDDK and the subcommittee to
    pursue these research goals in the coming years.
        For fiscal year 2010, CCFA joins with other patient and medical
    organizations in recommending a 7 percent increase in funding for the
    NIH. We specifically encourage the subcommittee to support the
    invaluable work of the NIDDK and NIAID.
                centers for disease control and prevention (cdc)
    IBD Epidemiology Program
        Mr. Chairman, as I mentioned earlier CCFA estimates that 1.4
    million people in the United States suffer from IBD, but there could be
    many more. We do not have an exact number due to these diseases'
    complexity and the difficulty in identifying them.
        We are extremely grateful for your leadership in providing funding
    over the past 5 years for an epidemiology program on IBD at CDC. This
    program is yielding valuable information about the prevalence of IBD
    and increasing our knowledge of the demographic characteristics of the
    IBD patient population. If we are able to generate an accurate analysis
    of the geographic makeup of the IBD patient population, it will provide
    us with invaluable clues about the potential causes of IBD.
        I should note that the latest phase of this project focuses on
    Rhode Island. The ``Ocean State Crohn's & Colitis Area Registry'' is
    identifying each new case of inflammatory bowel disease diagnosed in
    the State. The result will be a unique, population-based cohort of
    newly diagnosed patients to be followed prospectively over time--the
    first of its kind in the United States, and one of very few such
    cohorts in the world. The goals of the study include: (1) describing
    the incidence rates of Crohn's disease and ulcerative colitis; (2)
    describing disease outcomes; and (3) identifying factors that predict
    disease outcomes. To date more than 85 newly diagnosed patients of all
    ages have been enrolled into the study.
        Mr. Chairman, to continue this important epidemiological work in
    fiscal year 2010, CCFA recommends a funding level of $700,000, an
    increase of $16,000 more than fiscal year 2009.
                         pediatric ibd patient registry
        Mr. Chairman, the unique challenges faced by children and
    adolescents battling IBD are of particular concern to CCFA. In recent
    years we have seen an increased prevalence of IBD among children,
    particularly those diagnosed at a very early age. To combat this
    alarming trend CCFA, in partnership with the North American Society for
    Pediatric Gastroenterology, Hepatology and Nutrition, has instituted an
    aggressive pediatric research campaign focused on the following areas:
      --Growth/Bone Development.--How does inflammation cause growth
            failure and bone disease in children with IBD?
      --Genetics.--How can we identify early onset Crohn's disease and
            ulcerative colitis?
      --Quality Improvement.--Given the wide variation in care provided to
            children with IBD, how can we standardize treatment and improve
            patients' growth and well-being?
      --Immune Response.--What alterations in the childhood immune system
            put young people at risk for IBD, how does the immune system
            change with treatment for IBD?
      --Psychosocial Functioning.--How does diagnosis and treatment for IBD
            impact depression and anxiety among young people? What
            approaches work best to improve mood, coping, family function,
            and quality of life.
        The establishment of a national registry of pediatric IBD patients
    is central to our ability to answer these important research questions.
    Empowering investigators with HIPPA compliant information on young
    patients from across the Nation will jump-start our effort to expand
    epidemiologic, basic and clinical research on our pediatric population.
    We encourage the subcommittee to support our efforts to establish a
    Pediatric IBD Patient Registry with the CDC in fiscal year 2010.
        Once again Mr. Chairman, thank you very much for the opportunity to
    be with you today. I look forward to any questions you may have.
                                     ______

       Prepared Statement of the Children's Environmental Health Network
        The Children's Environmental Health Network (the Network)
    appreciates this opportunity to comment on the fiscal year 2010
    appropriations to the Departments of Health and Human Services and
    Education for activities that protect children from environmental
    hazards. The Network appreciates the wide range of priorities that you
    must consider for funding. We urge you to give priority to those
    programs that directly protect and promote children's environmental
    health. In so doing, you will improve not only our children's health,
    but also their educational outcomes and their future.
        The Network is a national organization whose mission is to promote
    a healthy environment and to protect the fetus and the child from
    environmental health hazards. We recognize that children, in our
    society, have unique moral standing. The Children's Environmental
    Health Network was created to promote the incorporation of basic
    pediatric facts such as these in policy and practice:
      --Children's bodies and behaviors differ from adults. In general,
            they are more vulnerable than adults to toxic chemicals.
      --Children are growing. Pound for pound, children eat more food,
            drink more water and breathe more air than adults. Thus, they
            are likely to be more exposed to substances in their
            environment than are adults. Children are different from adults
            in how their bodies absorb, detoxify, and excrete toxicants.
      --Children's systems, such as their nervous, reproductive, and immune
            systems, are developing. This process of development creates
            periods of vulnerability when toxic exposures may result in
            irreversible damage when the same exposure to a mature system
            may result in little or no damage.
      --Children behave differently than adults, leading to a different
            pattern of exposures to the world around them. For example,
            because of their hand-to-mouth behavior, they ingest whatever
            may be on their hands, toys, household items, and floors.
            Children play and live in a different space than do adults. For
            example, very young children spend hours close to the ground
            where there may be more exposure to toxicants in dust and
            carpets as well as low-lying vapors such as radon or
            pesticides.
      --Children have a longer life expectancy than adults; thus they have
            more time to develop diseases with long latency periods that
            may be triggered by early environmental exposures, such as
            cancer or Parkinson's disease.
        Clear, sound science underlies these principles. A solid consensus
    in the scientific community supports these concepts. The world in which
    today's children live has changed tremendously from that of previous
    generations. There has been a phenomenal increase in the substances to
    which children are exposed. According to the Environmental Protection
    Agency (EPA), more than 83,000 industrial chemicals are currently
    produced or imported into the United States. Traces of hundreds of
    chemicals are found in all humans and animals. Every day, children are
    exposed to a mix of chemicals, most of them untested for their effects
    on developing systems.
        We urge the subcommittee to provide the necessary resources for the
    Federal programs and activities that help to protect children from
    environmental hazards. The key programs in your jurisdiction are below.
       centers for disease control and prevention (cdc) and the national
                       environmental health center (nehc)
        The Network strongly supports the work of the CDC and the NEHC,
    especially NEHC's efforts to continue and expand its biomonitoring
    program and to continue its national report card on exposure
    information, using the highly respected National Health and Nutrition
    Examination Survey. A vital CDC responsibility in pediatric
    environmental health is to assist in filling the major information gaps
    that exist about children's exposures.
        The Network supports a funding level of $8.6 billion for CDC's core
    programs in fiscal year 2010. The Network urges the subcommittee to
    provide an additional $19.6 million for CDC's Environmental Health
    Laboratory in fiscal year 2010. The Network believes it is especially
    critical for the NEHC to gather and publish expanded information in the
    report card on children's exposures.
                             public health tracking
        The CDC's National Environmental Public Health Tracking Program
    helps to track environmental hazards and the diseases they may cause,
    coordinating and integrating local, State, and Federal health agencies'
    collection of critical health and environmental data. We urge the
    subcommittee to provide $50 million for the tracking network in fiscal
    year 2010 to expand it to additional States and support the continued
    development of a sustainable, nationwide Network.
        Additionally, data on children's ``real world'' exposure and
    disease are critically needed. Since children spend hours every day in
    school and child care, we urge you to direct the Tracking Program to
    include grants for pilot methods for tracking children's health in
    schools and child care settings.
                             global climate change
        We strongly urge the subcommittee to designate $50 million for the
    CDC to help the public prepare for and adapt to the potential health
    effects of global climate change in fiscal year 2010.
        Global climate change presents major challenges to public health.
    Children, as a vulnerable subpopulation, are among those at greatest
    risk of harm. Children in communities that are already disadvantaged
    will be the most harmed. Recent studies have detailed how children's
    physical and social health may be harmed, ranging from respiratory
    diseases and melanoma (due to atmospheric changes), to gastrointestinal
    diseases (due to increased water contamination), to an increased range
    for some diseases (malaria, dengue, encephalitides, Lyme disease), to
    increased rates of malnutrition (due to severe drought and severe
    precipitation), to the harm caused by displacement, water and food
    insecurity, and forced migration (caused by drought, increased rain and
    severe storms, and rising sea levels) and the resulting international
    conflict and political unrest.
        It is imperative that the Federal Government undertake efforts to
    mitigate and adapt to climate change. Providing funding to the CDC for
    preparing for the potential health effects of global climate change is
    an important step.
        national institute of environmental health sciences (niehs) and
         children's environmental health research centers of excellence
        NIEHS is a vital institution in our efforts to understand how to
    protect children, whether it is identifying and understanding the
    impact of substances that are endocrine disruptors, or better
    understanding childhood exposures that may not affect health until
    decades later, or seeking answers to many other important questions.
        The Children's Environmental Health Research Centers, funded by
    NIEHS and the EPA, play a key role in protecting children from
    environmental hazards. With budgets of $1 million per year per center
    (unchanged over more than 10 years), this program generates valuable
    research. A unique aspect of this program is the requirement that each
    Center actively involves its local community in a collaborative
    partnership, leading both to community-based participatory research
    projects and to the translation of research findings into child-
    protective programs and policies. Researchers have embraced this
    funding mechanism because of the ability it gives them to do
    interdisciplinary research and to be involved in the community--things
    that are not easy to do using other grant mechanisms. The scientific
    output of these centers has been outstanding. For example, four of the
    Centers had findings that clearly showed that prenatal exposure to a
    widely used pesticide affected developmental outcomes at birth and
    early childhood. Another recent example is the finding of a biomarker
    in newborns for childhood leukemia, firmly establishing the important
    role of prenatal environment factors in causation of this disease.
        Unfortunately, almost all of the existing 12 centers are currently
    operating on no-cost extensions. We strongly support the center concept
    and the network of centers. We also support current efforts by NIEHS
    and the EPA to competitively renew and to expand this valuable program
    by adding four formative centers. However, only five of the existing
    centers are to be renewed. If centers are shuttered, we will lose
    access to valuable populations such as urban children with asthma or
    children in farm communities exposed to pesticides. We will lose the
    ability to learn about issues like early puberty concerns, exposures in
    school settings, and pre-adolescent and adolescent outcomes.
        Thus, we urge the subcommittee to appropriate at least $15 million
    for the NIEHS share of funding so that, in concert with the EPA
    contribution, an adequate number of centers (old and new) will have
    funding in fiscal year 2010.
        In addition, the Network urges the subcommittee to support NIEHS by
    increasing its overall budget, and that of the Superfund research
    program, by 5 percent more than last year's level and directing that
    included in this increase would be a $5 million increase specifically
    for research on children's environmental health issues. The Superfund
    research program has supported some vital children's research but
    funding has been level over the last 4 years.
                        national children's study (ncs)
        The NCS is examining the effects of environmental influences on the
    health and development of more than 100,000 children in 105 communities
    across the United States, following them from before birth until age
    21. The NCS will be one of the richest research efforts ever geared
    toward studying children's health and development and will form the
    basis of child health guidance, interventions, and policy for
    generations to come. The NCS will provide a better understanding of how
    children's genes and their environments interact to affect their health
    and development, thus improving the health and well-being of all
    children.
        Enrollment in the NCS began this January, after 8 years of planning
    and development. The Network urges the subcommittee to continue its
    enthusiastic support for the NCS in this and future years, including
    full funding of $195 million in fiscal year 2010. The Network also asks
    the subcommittee to direct the National Institute of Child Health and
    Human Development to assure that protocols are in place for measuring
    exposures in the child care and school settings. The Network believes
    it is critically important to understand how school and child care
    exposures differ from home exposures very early in the NCS.
             pediatric environmental health specialty units (pehsu)
        A key, but dramatically underfunded, program is the PEHSU network.
    Funded by the Agency for Toxic Substances and Disease Registry and the
    EPA, the PEHSUs form a network with a center in each of the U.S.
    Federal regions, plus one center in Canada and one in Mexico. PEHSU
    professionals provide quality medical consultation for health
    professionals, parents, caregivers, and patients. Last year, the entire
    program, covering the 10 U.S. centers, received less than $2 million.
    These centers have done tremendous work on these small budgets. We urge
    the subcommittee to provide funding for this program in fiscal year
    2010 at the level of $200,000 per center (compared to the $120,000 for
    each center last year).
                          school environmental health
        Each school day, about 54 million children and 7 million adults
    spend a full week inside schools. Unfortunately, many of the Nation's
    public and private school facilities are shoddy or even ``sick''
    buildings whose environmental conditions harm children's health and
    undermine attendance, achievement, and productivity. In 1996, GAO
    reported that more than 13 million children were compelled to be in
    schools that threatened their health and safety. Two Federal statutes
    that would create a foundation for healthy schools are already in
    place, authorizing the U.S. Department of Education and the EPA to
    address school environments. Unfortunately, to date neither of these
    programs have been funded.
        We strongly urge the subcommittee to provide the $25 million
    authorized by the Healthy and High Performance Schools Act (Public Law
    107-110) to the grant program for State agencies to develop and
    disseminate information and assistance on high performance school
    design standards. The subcommittee should also direct the Department of
    Education to conduct a National Priority Study, as required under HHPS,
    on the impacts of decayed facilities on children and to report to
    Congress. To date, Education has only produced a brief review of the
    scientific literature.
        These programs and activities are especially vital in light of the
    ``stimulus'' funds for school modernization or renovation. The stimulus
    bill does not require consideration of environmental health or
    children's health and safety. Yet, without specific consideration of
    health, steps to ``green'' a school--such as increasing insulation at a
    school to improve energy efficiency--can have unintended harmful side
    effects, such as creating or exacerbating indoor air quality problems.
                        child care environmental health
        Thirteen million preschoolers--60 percent of young children--are in
    child care. Millions of preschoolers--our youngest and most vulnerable
    population--enter care as early as 6 weeks of age and can be in care
    for more than 40 hours per week. Yet little is known about the
    environmental health status of our child care centers nor how to assure
    that they are protecting this important group of children. The Network
    is working to correct these gaps.
        We ask the subcommittee to direct the Department of Health and
    Human Services Assistant Secretary for Children and Families to report
    on the Administration for Children and Families activities that protect
    children from environmental hazards in childcare settings, especially
    in the Office of Head Start.
        In conclusion, investments in programs that protect and promote
    children's health will be repaid by healthier children with brighter
    futures, an outcome we can all support. That is why the Network asks
    you to give priority to these programs. Thank you for the opportunity
    to testify on these critical issues.
                                     ______

              Prepared Statement of the Cystic Fibrosis Foundation
                      national institutes of health (nih)
        On behalf of the Cystic Fibrosis Foundation (CFF), and the 30,000
    people with cystic fibrosis (CF), we are pleased to submit the
    following testimony regarding fiscal year 2010 appropriations for CF-
    related research at NIH and other agencies.
                                    about cf
        CF is a life-threatening genetic disease for which there is no
    cure. People with CF have two copies of a defective gene, known as
    CFTR, which causes the body to produce abnormally thick, sticky mucus
    that clogs the lungs and results in fatal lung infections. The thick
    mucus in those with CF also obstructs the pancreas, making it difficult
    for patients to absorb nutrients from food.
        Since its founding, CFF has maintained its focus on promoting
    research and improving treatments for CF. More than thirty drugs are
    now in development to treat CF, some which treat the basic defect of
    the disease, while others target its symptoms. Through the research
    leadership of CFF, the life expectancy of individuals with CF has been
    boosted from less than 6 years in 1955 to 37 years in 2007. This
    improvement in the life expectancy for those with CF can be attributed
    to research advances and to the teams of CF caregivers who offer
    specialized care. Although life expectancy has improved dramatically,
    we continue to lose young lives to this disease.
        The promise for people with CF is in research. In the past 5 years,
    the CFF has invested more than $660 million in its medical programs of
    drug discovery, drug development, research, and care focused on life-
    sustaining treatments and a cure for CF. A greater investment is
    necessary, however, to accelerate the pace of discovery and development
    of CF therapies. This testimony focuses on the investment required to
    more rapidly and efficiently discover and develop new CF treatments
    aimed at controlling or curing CF.
            sustaining the federal investment in biomedical research
        This subcommittee and Congress are to be commended for their
    steadfast support for biomedical research, and their commitment to the
    National Institutes of Health (NIH), particularly the effort to double
    the NIH budget between fiscal year 1999 and fiscal year 2003 as well as
    the significant investment provided by the American Recovery and
    Reinvestment Act (ARRA). These increases in funding brought a new era
    in drug discovery that has benefited all Americans. Congress must
    adequately fund the NIH so that it can capitalize on scientific
    advances in order to maintain the momentum that the doubling and the
    infusion of funds from ARRA generated.
        The flat-funding of the NIH since 2003 has decreased purchasing
    power, limiting the pursuit of critical research. CFF joins the
    Coalition for Health Funding to recommend increasing the budget for all
    health discretionary spending by 13 percent in fiscal year 2010, or
    $7.4 billion over the fiscal year 2009 Omnibus. This increased
    investment will help maintain the NIH's ability to fund essential
    biomedical research today that will provide tomorrow's care and cures.
    If the subcommittee is not able to recommend funding at this level,
    Congress should advise the NIH to focus on contributing funds to
    research partnerships that will accelerate therapeutic development to
    improve peoples' lives.
               strengtheing our nation's research infrastructure
        Because CF is a disease that impacts several systems in the body,
    several Institutes at the NIH share responsibility for CF research. We
    urge the NIH to pay special attention to advances in treatment methods
    and mechanisms for translating basic research across Institutes into
    therapies that can benefit patients across Institutes. CFF has been
    recognized for its own research approach that encompasses basic
    research through phase III clinical trials, and has created the
    infrastructure required to accelerate the development of new CF
    therapies. As a result, we now have a pipeline of more than 30
    potential therapies that are being examined to treat people with CF.
              the clinical and translational science awards (ctsa)
        CTSA program was a key component of the NIH's Roadmap initiative.
    The program is designed to transform how clinical and translational
    research is conducted, ultimately enabling researchers to provide new
    treatments more efficiently to patients. Tremendous effort brought
    institutions together to rally around this program, yet current funding
    levels make it difficult for the 39 programs (out of a planned 60) to
    succeed.
        Key to the success of the CTSAs is the development of cost-sharing
    for use of infrastructure services. An example of this mechanism is the
    General Clinical Research Centers (GCRC), which allowed Institutes to
    reduce their research budgets by having investigators use the GCRC when
    clinical care such as inpatient stays, lab tests, nursing staff, was
    made available at no additional cost. Today, individual investigators
    must provide funds for clinical care cost-sharing from grants funded
    from other NIH Institutes. As research becomes more expensive and
    private capital dries up, it becomes even more critical to ensure
    support for translational research, that is, research that moves a
    potential therapy from development to the market. In order to maximize
    the potential of the CTSA, multiple Institutes within NIH must be able
    to provide financial resources for this critical program.
    Supporting Clinical Research
        A significant discrepancy persists between the funding awarded to
    clinical and basic laboratory investigators for first awards. The
    difference is even greater for second awards and prolonged funding of
    clinical investigators. The NIH must maintain support for translational
    research and the investigators piloting those projects. Without this
    support, the NIH stands to lose an entire generation of clinically
    trained individuals committed to clinical research. The ``generation
    gap'' that would be created by the loss of these clinical researchers
    would affect the ability of the NIH to conduct world-class clinical
    investigation and jeopardize the standing of the United States as the
    world's premiere source for biomedical research.
              facilitating clinical research and drug development
        CFF applauds the NIH's efforts to encourage greater efficiency in
    clinical research. CFF has been a leader in creating a clinical trials
    network to achieve greater efficiency in clinical investigation.
    Because the CF population is so small, a more significant portion of
    people with the disease must partake in clinical trials than in most
    other diseases. This unique challenge prompted CFF to streamline our
    clinical trials processes. Research conducted by CFF is more efficient
    than ever before and we are a model for other disease groups.
    The Model of the Cystic Fibrosis Therapeutics Development Network
        CFF's established clinical research program, the Therapeutics
    Development Network (TDN), plays a pivotal role in accelerating the
    development of new treatments to improve the length and quality of life
    for CF patients. Lessons learned from its centralization of data
    management and analysis and data safety monitoring in the TDN will be
    useful in designing clinical trial networks in other diseases. We urge
    the subcommittee to direct the NIH and other agencies to allocate
    additional funds for innovative therapeutics development models like
    the TDN. CFF urges the subcommittee to allocate additional resources
    for clinical research in order meet the demand for testing the
    promising new therapies for CF and other diseases.
    Alterative Models for Institutional Review Boards
        We are pleased that the Department of Health and Human Services has
    encouraged the exploration of alternative models of IRBs, including
    central IRBs, by the CTSA. We encourage Congress to urge the Department
    to demonstrate more aggressive leadership in persuading all academic
    institutions to accept review by a central IRB--without insisting on
    parallel and often duplicative review by their own IRB--at least in the
    case of multi-institutional trials in rare diseases. Such oversight
    could help provide greater expertise to improve trial design and enable
    critical research to move forward in a timelier manner without
    undermining patient safety.
          research compensation for supplemental security income (ssi)
        An additional impediment in our effort to accelerate the
    development of new therapies is the Social Security Administration's
    (SSA) current SSI rules, which count research compensation for
    participation in a clinical drug study as income for determining SSI.
    This policy creates an unnecessary barrier to clinical trial
    participation for a significant number of people with CF, and thus
    severely limits efforts to develop new therapies. We urge the
    subcommittee to direct the SSA to disregard any compensation to an
    individual who is participating in a clinical trial testing rare
    disease treatments that has been reviewed and approved by an
    institutional review board and meets the ethical standards for clinical
    research for the purposes of determining that individual's eligibility
    for the SSI program.
    Partnership with the National Center for Research Resources (NCRR)
        The CTSA program, administered by the NCRR, encourages novel
    approaches to clinical and translational research, enhances the
    utilization of informatics, and strengthens the training of young
    investigators. CFF has enjoyed a productive relationship with the NCRR
    to support our vision for improving clinical trials capacity through
    its early financial support of the TDN. Recently, however, the NCRR
    decided to reject funding for disease-specific networks in favor of
    those without a disease focus. As a result of this policy, some of the
    best clinical research consortia are prohibited from competing for NCRR
    grants, including but not limited to the CF TDN. We urge the NCRR to
    reverse this decision.
                           supporting drug discovery
        CFF's clinical research is fueled by a vigorous drug discovery
    effort; early stage translational research of promising strategies to
    find successful treatments for this disease. Several research projects
    at the NIH will expand our knowledge about the disease, and could
    eventually be the key for controlling or curing CF.
    Exploring Protein Misfolding and Mistrafficking
        We applaud the National Heart, Lung and Blood Institute (NHLBI),
    and the National Institute of Diabetes and Digestive and Kidney
    Diseases (NIDDK) for their initiatives that target research on protein
    misfolding, and urge an aggressive commitment to facilitate continued
    exploration in this area to build upon promising discoveries. We urge
    the NIH to continue to devote special attention to research in protein
    misfolding and mistrafficking, an area which could yield significant
    benefits for patients with CF and other diseases where misfolding is an
    issue.
    Opportunities In Animal Models
        CFF is encouraged by the NIH's investment in a research program at
    the University of Iowa to study the effects of CF in a pig model. The
    program, funded through research awards from both NHLBI and CFF, bears
    great promise to help make significant developments in the search for a
    cure. While a company has been established to produce the animals, the
    infrastructure and extensive animal husbandry required to keep the
    animals alive and conduct research on them is available at few academic
    institutions. We urge additional funding to create a facility that
    would enable researchers from multiple institutions to conduct research
    with these models.
    Facilitating Scientific Data Connections
        An explosion of data is emerging from ``big science'' projects such
    as the Human Genome Project and the International HapMap Project. We
    encourage investments by NIH into the development of systems that
    permit the linkage of gene expression, protein expression and protein
    interaction data from independent laboratories. While construction of
    such an interface would be difficult, it would undoubtedly facilitate
    generations of new ideas and open new areas of medically important
    biology.
    Increasing Investment in Inflammatory Response Research
        CF, like diseases such as inflammatory bowel disease, chronic
    bronchitis, and rheumatoid arthritis, cause an intense inflammatory
    response. CFF enthusiastically supports investments by the NIH to gain
    a greater understanding of inflammatory signaling and inflammatory
    cascades, which would lead to improved methods of safely interfering
    with the inflammatory process and contributing to the health and well
    being of the U.S. population.
    Supporting High Throughput Screening
        The subcommittee should urge the NIH to continue to fund high
    throughput screening initiatives in keeping with the NIH Roadmap
    suggestions. Support for the follow-up and optimalization of compounds
    identified through this type of screening can help to bridge the
    development gap and bring about more drugs that can make it to
    patients' bedsides.
    Funding Systems Biology Platforms
        In order to rapidly accelerate the identification of potential
    biomarkers and understand the mechanisms of action of CFTR function,
    data generated from multiple laboratories and scientific must be
    integrated. To address this, CFF has partnered with a systems biology
    company called GeneGo to generate a CF-focused systems biology platform
    to illustrate the various effects of CFTR dysfunction in multiple cell
    systems. CFF urges NIH to provide additional funding to support
    research efforts aimed at leveraging systems biology platforms to
    integrate multiple disciplines within the CF research community in
    order to accelerate drug development and biomarker validation for CF.
    Small Business Innovation Research Program at NIH
        Small Business Innovation Research (SBIR) program grants allocated
    by the NIH have helped many small biotechnology and pharmaceutical
    companies to develop vital treatments for a variety of diseases.
    Several companies developing CF treatments have used SBIR grants to
    fund their development process.
        The SBIR program could provide further support by directing that a
    portion of all grants awarded be used for rare disease research. With
    such a small portion of the population likely to purchase the drugs,
    research to produce drugs to treat rare diseases is often considered
    too large a financial risk to take on. It is important to note, however
    that there are more than 25 million Americans with a rare disease. By
    directing even small dollar grants to develop drugs for these diseases,
    Congress can eliminate some of the risk that keeps biotechnology and
    pharmaceutical companies from developing drugs for rare diseases.
        The NIH has wisely focused on translational research as a
    touchstone for ensuring the relevance of the agency to the American
    public. CFF is the perfect example of this notion, having devoted our
    own resources to developing treatments through drug discovery, clinical
    development, and clinical care. Several of the drugs in our pipeline
    show remarkable promise in clinical trials and we are increasingly
    hopeful that these discoveries will bring us even closer to a cure.
    Encouraged by our successes, we believe the experience of CFF in
    clinical research can serve as a model of drug discovery and
    development for research on other orphan diseases and we stand ready to
    work with NIH and congressional leaders. On behalf of CFF, we thank the
    subcommittee for its consideration.
                                     ______

           Prepared Statement of the Center for Global Health Policy
        The Center for Global Health Policy of the Infectious Diseases
    Society of America (IDSA) is pleased to submit testimony about the
    urgent need to increase funding for the Department of Health and Human
    Services' programs that address two deadly global pandemics--HIV/AIDS
    and tuberculosis.
        IDSA represents more than 8,000 infectious diseases and HIV
    physicians and scientists devoted to patient care, education, research,
    prevention, and public health. Nested within the IDSA is the HIV
    Medicine Association (HIVMA), representing more than 3,500 physicians,
    scientists, nurse practitioners, and other health professionals working
    in HIV medicine. In 2008, IDSA and HIVMA launched the Infectious
    Diseases Center on Global Health Policy and Advocacy to address global
    HIV/AIDS, tuberculosis, and HIV/TB co-infection. Under the leadership
    of a scientific advisory committee of world-renowned scientific experts
    in these areas, IDSA works to educate policymakers, U.S. Government
    program implementers and the media about evidence-based policies and
    programs and the value of U.S. leadership in combating these deadly and
    synergistic epidemics.
                            global hiv/aids pandemic
        There are 33 million people living with HIV/AIDS in the world, with
    22 million of them or 67 percent living in sub-Saharan Africa. AIDS
    kills 2 million people annually. U.S. leadership has been the
    catalyzing force for preventing millions of infections, ensuring access
    to lifesaving HIV treatment for 3 million persons in developing
    countries, and providing care and support to millions of additional
    people, including orphans and vulnerable children. Despite tremendous
    progress, only about one-third of persons in developing countries who
    are clinically eligible for antiretroviral therapy are receiving it,
    and an ongoing and robust prevention campaign is essential to reduce
    the more than 7,000 new HIV infections that still occur on a daily
    basis.
        The National Institutes of Health (NIH)-funded HIV research at the
    NIH research led to the development of lifesaving antiretroviral
    therapy, identified the efficacy of antiretroviral therapy during
    pregnancy to prevent mother-to-child transmission, demonstrated the HIV
    prevention benefits of male circumcision, and is paving the road to the
    availability of an effective microbicide. The Centers for Disease
    Control and Prevention (CDC) have been a critical implementing partner
    in the U.S. response to the global HIV epidemic, working with health
    ministries in developing countries to launch HIV prevention and
    treatment programs, conducting public health evaluation research, and
    supporting heavily impacted countries in their efforts to monitor and
    to employ evidence based strategies in response to their particular
    epidemics.
                                  tuberculosis
        Tuberculosis is the second leading global infectious disease
    killer, claiming more than 1.7 million lives annually. Worldwide, one-
    third of the world's population is infected with TB and nearly 9
    million people develop active TB disease each year. In recent years,
    highly drug-resistant forms of TB have emerged. Drug-resistant
    tuberculosis is a direct result of human failure--failure to adequately
    detect and treat TB and to develop the necessary tools to effectively
    address this ancient and deadly scourge.
        In 2006, the CDC and the World Health Organization (WHO) reported
    the findings from a survey of TB reference laboratories around the
    world indicating that 20 percent of M. tuberculosis isolates were
    multi-drug resistant (MDR)--that is, TB strains resistant to the two
    most potent drugs in the four-drug TB regimen. Four percent of these
    MDR-TB strains were resistant to multiple second-line drugs and were
    deemed extensively drug-resistant TB or XDR-TB. Mortality from XDR-TB
    can be as high as 85 percent, and close to 100 percent in individuals
    co-infected with HIV/AIDS. The increase in MDR-TB and the advent of
    XDR-TB have triggered grave alarm in the scientific community about the
    potential for an untreatable XDR-TB epidemic. In 2007, WHO estimated
    that there were 500,000 cases of MDR-TB and only 1 percent of these
    cases were treated according to WHO standards.
        The global pandemic and alarming spread of drug-resistant TB
    present a persistent public health threat to the United States.
    Tuberculosis is an airborne infection.
        Drug-resistant TB anywhere in the world easily translates into
    drug-resistant TB everywhere.
                     deadly synergy of hiv/tb co-infection
        The costly MDR TB epidemic in the United States in the early 1990s
    emerged against a background of HIV infection in high HIV prevalence
    cities like New York City and Miami. Today, HIV-TB co-infection is
    ravaging sub-Saharan Africa. TB is the leading cause of death of
    persons with HIV worldwide. Tuberculosis facilitates HIV disease
    progression, and persons with HIV have poorer TB treatment outcomes
    than their non-HIV-infected counterparts. According to the WHO, in
    2007, there were at least 1.37 million cases of HIV positive TB--nearly
    15 percent of the total incident cases. There were 456,000 deaths among
    this group.
                               cdc--tuberculosis
        Last year, Congress passed landmark legislation--the Comprehensive
    Tuberculosis Elimination Act of 2008--Public Law 110-873. This bill
    authorizes a number of actions that will shore up State TB control
    programs, enhance United States capacity to deal with the serious
    threat of drug-resistant tuberculosis and escalate our efforts to
    develop urgently needed new ``tools'' in the form of drugs,
    diagnostics, and vaccines. Realizing these goals will require
    additional resources; at a minimum, it is critical that the funding
    authorized for fiscal year 2010 in this important new law--$210
    million--be appropriated for the CDC Division of TB Elimination. While
    this represents an increase more than current funding, the scientific
    community, including the National Coalition for the Elimination of
    Tuberculosis, has estimated that $528 million will be needed annually
    to implement strategies through the CDC that will advance the goal of
    TB elimination.
        Funds are desperately needed to increase the clinical trial
    capacity of the Tuberculosis Trials Consortium (TBTC) to evaluate
    promising new drugs for MDR TB and to support clinical trials for
    vaccine candidates that hold the hope of eliminating the scourge of TB
    from the face of the earth. Additional financial support is also needed
    for the Tuberculosis Epidemiologic Studies Consortium (TBESC)--critical
    partnerships between TB control programs and academic institutions
    aimed at designing, conducting and evaluating programmatically relevant
    research.
        Strengthening CDC's Division of TB Elimination to conduct research
    and support State TB control programs will protect our communities, and
    help ensure that another devastating outbreak of drug-resistant
    tuberculosis that plagued several American cities in the late 1980s
    does not recur. Ultimately, modest Federal investments will prevent the
    necessity to expend huge resources treating MDR-TB and XDR-TB, which
    can cost $468,000 per case to treat.
                         cdc--global aids program (gap)
        CDC's Global AIDS Program (GAP) helps resource-poor countries
    prevent HIV infection; improve treatment, care, and support for people
    living with HIV; and build healthcare capacity and infrastructure. To
    meet these objectives, CDC sends clinicians, epidemiologists and other
    health professionals to help foreign governments and health
    institutions with a range of prevention, care, and support activities.
    Working closely with health ministries in developing countries, CDC
    helps build sustainable public health capacity in laboratory services
    and systems, including country capacity to design and implement HIV
    surveillance systems and surveys.
        The CDC GAP also plays an important role in helping governments
    monitor and evaluate the impact of HIV prevention, care and treatment
    programs. CDC GAP also works with the Office of the Global AIDS
    Coordinator as the lead on HIV prevention, and also works to evaluate
    the impact of US HIV prevention, treatment and care and support
    funding. For example, CDC GAP is currently conducting a public health
    evaluation (PHE) to assess the impact of PEPFAR funding on developing
    country health systems and access to other healthcare services. A
    funding level for CDC'GAP program of at least $218 million is
    essential.
                                      nih
        NIH is the world's flagship biomedical research institution,
    supporting basic science research, behavioral research, drug and
    diagnostic development and research training. Unfortunately in recent
    years, NIH funding has eroded, and stagnant funding has resulted in
    decreasing support for original research and cuts in clinical trial
    networks. With only 1 in 4 approved research applications receiving
    funding, the pipeline for critical discoveries is dwindling and young
    scientists are being forced to turn their attention to different
    professional pursuits.
        IDSA is extremely pleased that the recently enacted stimulus bill
    contained an infusion of billions of desperately needed dollars for the
    NIH research enterprise. Congress rightfully acknowledged the role of
    scientific research in stimulating the economy. It is vital, however,
    that the long overdue increases in funding enjoyed by the NIH in the
    economic stimulus bill are maintained and enhanced in this year's
    funding bill--funding that will ultimately translate into improvements
    in individual and public health, both domestically and globally.
                               hiv/aids research
        The successes of the HIV research investment is a testament to the
    value of research investment. A robust and comprehensive research
    portfolio was responsible for the rapid and dramatic gains in our HIV
    knowledge base, gains that resulted in reductions in mortality from
    AIDS of nearly 80 percent in the United States and in developing
    countries where treatment has been made available. Remarkable
    discoveries helped us to reduce mother-to-child HIV transmission to
    nearly 1 percent in the United States and this intervention has
    prevented HIV infection in hundreds of thousands of children worldwide.
    A continued robust HIV research effort is essential to accelerate our
    progress in developing more effective prevention strategies, and
    supporting the basic research necessary to continue our work developing
    a vaccine that may end the deadliest pandemic in human history.
    Research to improve treatment strategies to aid prevention and to
    maximize the benefits of antiretroviral therapy, especially in
    underserved populations in the United States and in resource-limited
    settings is a high priority.
        The National Institute on Allergies and Infectious Diseases (NIAID)
    is the principal funding resource for basic and clinical HIV research,
    but critical HIV research is conducted through a range of NIH
    Institutes under the leadership of the Office for AIDS Research (OAR).
                             tuberculosis research
        NIAID is also a critical player in tuberculosis research. In 2007,
    NIAID developed a research strategy for drug-resistant tuberculosis,
    but limited resources have slowed implementation of this strategy.
    According to the NIH Research Portfolio Online Reporting Tool, RePORT,
    NIH funding for tuberculosis research, including vaccine research
    totaled $160 million in fiscal year 2008--a modest level for an
    infectious disease that kills millions through a pathogen that is
    showing increasing resistance to available medications. In fact,
    funding for TB research has gone in the wrong direction since NIH spent
    $211 million on TB research in fiscal year 2007. A doubling of funding
    for TB research would be a reasonable response to the world disease
    burden and the current scientific opportunities.
        We must increase our investment in TB research as highlighted in
    the enacted Comprehensive TB Elimination Act of 2008. We must have the
    resources to conduct clinical trials on new therapeutics for both drug-
    susceptible and drug-resistant TB, to test new diagnostics in point-of-
    care settings, and to evaluate promising TB vaccine candidates. We
    urgently need treatment regimens that are shorter in duration and less
    toxic. Research related to pediatric tuberculosis, including drug
    development, must be stepped up.
        It is also imperative that research activities focused on HIV/TB
    co-infection continue with enhanced funding. Tuberculosis is the
    leading cause of death among persons with HIV/AIDS worldwide. TB is
    more difficult to diagnose in persons with HIV and a number of
    important anti-TB drugs interact with HIV antivirals. Critical
    questions remain about how best to sequence HIV and TB treatment in co-
    infected individuals--questions with life and death ramifications for
    millions of individuals, especially those living in sub-Saharan Africa.
    Tuberculosis threatens to undermine the tremendous progress that has
    been made in saving the lives of persons in developing countries
    through the provision of antiretroviral therapy.
              global fund to fight aids, tuberculosis and malaria
        Historically, one-third of U.S. funding for the Global Fund has
    been appropriated through the NIAID budget and IDSA strongly supports a
    significant U.S. contribution to the Global Fund. U.S. support for the
    Global Fund to Fight AIDS, Tuberculosis and Malaria is a crucial part
    of U.S. global health diplomacy. The Global Fund is a country-led,
    performance-based partnership that embraces transparency and
    accountability, and fosters multilateral cooperation. The Global Fund
    provides a quarter of all international financing for AIDS globally,
    two-thirds for tuberculosis, and three-quarters for malaria. Through
    these efforts, the Global Fund has helped save 3.5 million lives in 140
    countries
        In Pakistan, for example, an American-based international aid group
    called Mercy Corps has, using Global Fund resources, partnered with the
    private sector on a broad TB public education campaign, training
    thousands of health workers, and strengthening lab capacity to test for
    TB. This work has dramatically increased Pakistan's ability to detect
    TB cases, and now Pakistan is counting on the Fund's strong, continued
    support to ensure medication is available to people with TB. Continued
    progress on TB is essential to development in Pakistan, since 80
    percent of Pakistanis afflicted with tuberculosis are in the most
    economically productive years of their lives, and the disease sends
    many self-sustaining families into poverty.
        The Global Fund projects an $8 billion need for new and continuing
    programs in 2010, but only $3 billion in pledges are in place. The
    Labor, Health and Human Services, and Education, and Related Agencies
    budget, through NIH, has been a crucial source of funding for the U.S.
    contribution to the Fund, providing $300 million in fiscal year 2009.
    The Global Fund has requested that the United States triple its total
    contribution for fiscal year 2010. The portion of the U.S. contribution
    provided by NIH should therefore be tripled to $900 million. The
    economic, strategic and moral case for this contribution to the Global
    Fund is clear, and the United States must do its part to help close
    this funding gap.
        The IDSA and the HIVMA have many funding priorities to champion in
    the Labor, Health and Human Services, and Education, and Related
    Agencies appropriations bill including funds to address antimicrobial
    resistance, child and adult immunizations, pandemic influenza, the Ryan
    White CARE Act, and domestic HIV prevention. Thank you for the
    opportunity to highlight our funding priorities for research and
    programs related to global HIV and TB in the Labor, Health and Human
    Services, and Education, and Related Agencies account.
                                     ______

       Prepared Statement of Children and Adults with Attention-Deficit/
                         Hyperactivity Disorder (CHADD)
                                   background
        At the Centers for Disease Control and Prevention (CDC) 1999
    conference titled ``Attention Deficit Hyperactivity Disorder: A Public
    Health Perspective,'' more than 150 experts gathered to discuss the
    public health concerns related to AD/HD and to explore areas for future
    research. The conference developed a public health research agenda
    which included recommendations on the establishment of: a resource for
    both professionals and the public regarding what is known about the
    epidemiology of AD/HD; an avenue of dissemination of educational
    materials related to the diagnosis of and intervention opportunities
    for AD/HD to primary care physicians, nurse practitioners, physicians
    assistants, mental health providers and educators; collaborations with
    other organizations to educate and promote what is known about AD/HD
    interventions, appropriate standards of practice, their effectiveness,
    and their safety; and a resource to the public for accurate and valid
    information about AD/HD and evidence-based interventions.
        Congress responded to this research agenda in fiscal year 2002 by
    providing resources for the CDC to begin a partnership with CHADD \1\
    to develop the National Resource Center on AD/HD (NRC)--a significant
    development in recognizing the unique challenges faced by individuals
    with AD/HD across the lifespan.
    ---------------------------------------------------------------------------
        \1\ Children and Adults with Attention-Deficit/Hyperactivity
    Disorder (CHADD) was founded by parents in 1987 in response to the
    frustration and sense of isolation experienced by parents and their
    children. CHADD is the leading national nonprofit organization for
    children and adults with AD/HD, providing the public and providers with
    education, advocacy, and support.
    ---------------------------------------------------------------------------
        The NRC's goals include improving the health and quality of life of
    individuals with AD/HD and their families; raising awareness and
    facilitating access to scientifically valid information and support
    services; and improving the understanding of the impact of AD/HD among
    healthcare specialists, educators, employers, and individuals with AD/
    HD. The NRC fulfills these goals by disseminating evidence-based
    research on AD/HD through a variety of mechanisms, including:
      --a Web site (www.help4adhd.org) receiving on average 129,274 visits
            each month;
      --a national call center, staffed by five professional health
            information specialists, including one bilingual health
            information specialist. The health information specialists
            responded to 9,051 individual inquiries during the last year on
            10,018 different topical issues from parents, adults with AD/
            HD, mental health professionals, and educators;
      --partnerships with minority health organizations to reach
            underserved populations;
      --a series of more than 25 ``What We Know'' fact sheets on AD/HD, in
            both English and Spanish; and
      --a comprehensive library and online bibliographic database of more
            than 3,000 evidence-based journal articles and reports on AD/
            HD.
        The overwhelming demand for information and support on AD/HD by the
    public and the professional community has created an unprecedented need
    for additional resources to keep pace with the requests for information
    received by the NRC and to provide outreach and resources to unserved
    and underserved populations.
                                 what is ad/hd?
        A 2005 report by the CDC found that parents reported approximately
    7.8 percent of school-age children (4 to 17 years) had a diagnosis of
    Attention-Deficit/Hyperactivity Disorder (AD/HD).\2\ Other evidence-
    based studies have documented that more than 70 percent of children
    with AD/HD will continue to experience symptoms of AD/HD into
    adolescence, and almost 65 percent will exhibit AD/HD characteristics
    as adults.\3\ In addition, up to two-thirds of children with AD/HD will
    have at least one co-occurring disability with 50 percent of these
    children having a co-occurring learning disability.
    ---------------------------------------------------------------------------
        \2\ Centers for Disease Control and Prevention (2005). Mental
    Health in the United States: Prevalence of Diagnosis and Medication
    Treatment for Attention-Deficit/Hyperactivity Disorder. Retrieved March
    25, 2005, from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5434a2.htm.
        \3\ Dulcan, M., and the Work Group on Quality Issues. (1997,
    October). AACAP official action: Practice parameters for the assessment
    and treatment of children, adolescents, and adults with Attention-
    Deficit/Hyperactivity Disorder. Journal of the American Academy of
    Child and Adolescent Psychiatry, Supplement, 36(10), 85S-121S.
    ---------------------------------------------------------------------------
        Only half of all children with AD/HD receive the necessary
    treatment, with lower diagnostic and treatment rates among girls,
    minorities, and children in foster care. If untreated or inadequately
    treated, AD/HD can have serious consequences, increasing an
    individual's risk for school failure, unemployment, interpersonal
    difficulties, other mental health disorders, substance and alcohol
    abuse, injury, antisocial and illegal behavior, contact with law
    enforcement, and shortened life expectancy.\4\ The availability of
    appropriate services and access to treatment can help individuals with
    AD/HD avoid negative outcomes and lead successful lives.
    ---------------------------------------------------------------------------
        \4\ Barkley, R. A. (1997). ADHD and the nature of self-control. New
    York: The Guilford Press.
    ---------------------------------------------------------------------------
                    fiscal year 2010 appropriations request
        The NRC has met and continues to meet the goals of improving the
    health and quality of life for individuals with AD/HD and their
    families; raising awareness and facilitating access to evidence-based
    information and support services; and improving the understanding of
    the impact of AD/HD among healthcare specialists, educators, employers,
    and individuals with AD/HD.\5\
    ---------------------------------------------------------------------------
        \5\ Cuffe, S.P., Moore, C.G., & McKeown, R. (2009). ADHD and health
    services utilization in the National Health Survey. Journal of
    Attention Disorders, 12(4), 330-340.; Chan, E., Zhan, C., & Homer, C.J.
    (2002). Health care use and costs for children with Attention-Deficit/
    Hyperactivity Disorder, Archives of Pediatrics & Adolescent Medicine,
    156, 504-511.; Rowland, A.S., Umbach, D.M., Stallone, L., Naftel, J.,
    Bohlig, E.M., & Sandler, D. P. (2002). Prevalence of medication
    treatment for Attention Deficit--Hyperactivity Disorder among
    elementary school children in Johnston County, North Carolina, American
    Journal of Public Health, 92(2), 231-234.; Ray, T.G., Levine, P.,
    Croen, L.A., Bokhari, F.A.S., Hu., T., & Habel, L.A. (2006). Attention-
    Deficit/Hyperactivity Disorder in children, Archives of Pediatrics &
    Adolescent Medicine, 160, 1063-1069.
    ---------------------------------------------------------------------------
        Both the National Institutes of Health Consensus Conference on AD/
    HD (Nov. 1998) and the Centers for Disease Control and Prevention (CDC)
    Conference on Public Health and AD/HD (September 1999) concluded that
    AD/HD is a serious public health concern that needs to be addressed
    because of the potential economic burden associated with AD/HD.
    Numerous peer-reviewed journal articles have documented the significant
    healthcare cost of individuals with AD/HD.
        In ``AD/HD in Adults: What the Science Says,'' Barkley, Murphy &
    Fisher discuss the results of the few empirical studies that have been
    conducted regarding occupational functioning of clinic-referred adults
    with AD/HD. ``Although opinions abound on the topic in trade books on
    ADHD in adults, there is very little research on the occupational
    functioning of clinic-referred adults with ADHD'' (p. 276). One study
    conducted at UMASS found that adults with a diagnosis of AD/HD are more
    likely to self-report and have employers report difficulties with
    occupational functioning than their clinic-referred or community
    counterparts. In addition, the Milwaukee study (2006) found that
    individuals diagnosed as having AD/HD as children that persists until
    age 27 tend to be more severely affected in occupational functioning
    than clinic-referred adults or community counterparts. In addition,
    another study conducted by Biederman & Faraone (2006) concluded that
    individuals with AD/HD are less likely to be employed full time (34
    percent of individuals with AD/HD compared to 59 percent of individuals
    without AD/HD).\7\ In addition, the study found that the household
    incomes of adults older than the age of 25 were significantly lower
    among individuals with AD/HD when compared to individuals without AD/HD
    regardless of academic achievement or personal characteristics. The
    results of these three studies indicate the need for further research
    into the impact of AD/HD on the occupational functioning of adults and
    how best to reasonably accommodate their disability in the workplace
    because more than 30 percent of requested accommodations are at no cost
    to the employer but yet according to Biederman & Faraone the total cost
    of work loss among men and women with AD/HD is $2.6 billion, or 53
    percent of the total $13 billion cost of adult ADHD in the United
    States.
    ---------------------------------------------------------------------------
        \7\ Biederman, J.,& Faraone, S.V. (2006). The effects of attention-
    deficit/hyperactivity disorder on employment and household income.
    MedGenMed, 8(3),12, Retrieved March 25, 2005, from http://
    www.medscape.com/viewarticle/536264.
    ---------------------------------------------------------------------------
        Therefore, we are asking that the National Center on Birth Defects
    and Developmental Disabilities (NCBDDD) AD/HD line item be increased
    from $1.777 million to $2.377 million and that the funding for the NRC
    be increased from $980,000 to $1.280 million. This is a $600,000
    increase in the AD/HD line and $300,000 increase in the NRC line.
    Historically, half of the increase to the AD/HD line item has been used
    to fund research on AD/HD. This increase will allow the NRC to further
    develop its outreach to the African-American and Hispanic-Latino
    communities, restore education campaigns at nurse, educator, and
    related conferences, and most importantly during this current economic
    climate to initiate an employment information specialist service.
                 requested report language for fiscal year 2010
        The subcommittee continues to support the activities of the CDC's
    NCBDDD and the National Resource Center (NRC) on AD/HD and has provided
    $2.377 million to continue this support, including $1.28 million to
    maintain and expand the activities at the NRC as it responds to the
    overwhelming demand for information and support services, reaches
    special populations in need, and educates health and education
    professionals on the impact of AD/HD on the ability individuals with
    AD/HD to lead successful, economically self-sufficient, and independent
    lives integrated into their communities with the necessary
    accommodations and supports.
                                     ______

        Prepared Statement of the Coalition for Health Services Research
        The Coalition for Health Services Research is pleased to offer this
    testimony regarding the role of health services research in improving
    our Nation's health. The Coalition's mission is to support research
    that leads to accessible, affordable, high-quality healthcare. As the
    advocacy arm of AcademyHealth, the Coalition represents the interests
    of 3,500 researchers, scientists, and policy experts, as well as 150
    organizations that produce and use health services research.
        Healthcare in the United States has the potential to improve
    people's health dramatically, but often falls short and costs too much.
    Health services research is used to understand how to better finance
    the costs of care, measure and improve the quality of care, and improve
    coverage and access to affordable services. Indeed, health services
    research is changing the face of American healthcare, uncovering
    critical challenges facing our Nation's healthcare system. For example,
    the 2000 Institute of Medicine (IOM) report To Err is Human found that
    up to 98,000 Americans die each year from medical errors in the
    hospital. Health services research also uncovered that disparities and
    lack of access to care in rural and inner cities result in poorer
    health outcomes. And, it found that obesity accounts for more than $92
    billion in medical expenditures each year and has worse effects on
    chronic conditions than smoking or problem drinking.
        Health services research does not just lift the veil on problems
    plaguing American healthcare; it also seeks ways to address them.
    Health services research framed the debate over healthcare reform in
    Massachusetts--forming the basis for that State's 2006 health reform
    legislation--and continues to frame the debate on the national stage
    today. It offers guidance on implementing and making the best use of
    health information technology, and getting the best care at the best
    value across a menu of treatment options. And there are increasing
    examples that demonstrate how comparative effectiveness research--an
    emerging science in the broader field of health services research--
    provides the scientific basis needed to determine what treatments work
    best, for whom, and in what circumstances.
        Health services research can contribute greatly to better
    healthcare at better value. It is a true public good, providing a basis
    for improvements in our healthcare system that will benefit the general
    public. Americans overwhelmingly agree. A recent opinion survey
    commissioned by Research!America found that 95 percent of Americans say
    it is important to support research focused on how well our healthcare
    system is functioning. After all, the investment in basic research and
    the development of new medicines and equipment is wasted if the health
    system cannot safely and effectively deliver that care.
        For the last 6 years, the Coalition has been collecting data to
    track the Federal Government's expenditures for health services
    research and health data. From information provided to us by these
    funders--including Agency for Healthcare Research and Quality (AHRQ),
    National Institutes of Health (NIH), and the Centers for Disease
    Control and Prevention (CDC)--funding for this field remained
    relatively constant from fiscal year 2003--2008 and did not kept pace
    with inflation. In stark contrast, spending on healthcare overall has
    risen faster than the rate of inflation--from $1.4 trillion in 2000 to
    nearly $2.2 trillion in 2007. The total Federal investment in health
    services research and data by our estimates approaches $1.7 billion in
    fiscal year 2008--representing just 0.074 percent of the $2.2 trillion
    we spend on healthcare annually.
        The Coalition for Health Services Research greatly appreciates the
    subcommittee's recent efforts to increase the Federal investment in
    health services research and comparative effectiveness research through
    the fiscal year 2009 Omnibus Appropriations Act and the American
    Recovery and Reinvestment Act of 2009. This funding provides a new high
    watermark for the field and represents the largest single funding
    increase health services research has experienced. With comprehensive
    health reform on the horizon, we ask that the subcommittee continue to
    strengthen the capacity of the health services research field to
    address the pressing challenges America faces in providing access to
    high-quality, cost-effective care for all its citizens.
                                      ahrq
        AHRQ is the lead Federal agency charged with supporting unbiased,
    scientific research to improve healthcare quality, reduce costs,
    advance patient safety, decrease medical errors, and broaden access to
    essential services. Steady, incremental increases for AHRQ's Effective
    Health Care Program in recent years, as well as the $300 million
    provided to AHRQ in the American Recovery and Reinvestment Act as a
    down payment on health reform will help AHRQ generate more comparative
    effectiveness research and expand the infrastructure needed to increase
    capacity to produce this evidence. However, funding for AHRQ's broader
    health services research portfolio on health disparities, healthcare
    financing and organization, and access and coverage has languished as
    funding for AHRQ's base has remained relatively flat. Future
    investments should bolster these other important research topics to
    balance the recent investments in comparative effectiveness research.
    Comparative effectiveness research alone will not solve our health
    system challenges; the full spectrum of health services research on
    healthcare costs, quality, and access will be needed to support broader
    health reform efforts.
        In fiscal year 2009, Congress provided AHRQ $13 million to reverse
    a decline in the number of, and funding for, grants that support
    researcher innovation and career development. AHRQ is using this
    funding for investigator initiated research grants to rejuvenate the
    free marketplace of ideas through the agency's new Innovations Research
    Portfolio. We request that Congress provide additional funding to
    sustain and expand investigator initiated grants in fiscal year 2010.
        The Coalition remains concerned about AHRQ's limited investment in
    training grants for young researchers, which hit new lows in fiscal
    year 2009--just 40 awards totaling $5 million--down from nearly double
    that amount just 2 years ago. The Coalition requests that Congress will
    provide AHRQ more funding in fiscal year 2010 for training grants to
    ensure the field's capacity to respond to the growing public and
    private sector demand for health services research.
        While targeted funding increases in recent years have moved AHRQ in
    the right direction, more core funding is needed to help AHRQ fulfill
    its mission. We join the Friends of AHRQ--a coalition of more than 250
    health professional, research, consumer, and employer organizations
    that support the agency--in recommending a fiscal year 2009 base
    funding level of at least $405 million, an increase of $32 million more
    than the fiscal year 2009 level. This investment will allow AHRQ to
    restore its critical healthcare safety, quality, and efficiency
    initiatives; strengthen the infrastructure of the research field; and
    reignite innovation and discovery.
                                      cdc
        Housed within CDC, the National Center for Health Statistics (NCHS)
    is the Nation's principal health statistics agency, providing critical
    data on all aspects of our healthcare system. Thanks to NCHS, we know
    that too many Americans are overweight and obese, cancer deaths have
    decreased, average life expectancy has increased, and emergency rooms
    are overcrowded. We also know how many people are uninsured, how many
    children are immunized, how many Americans are living with HIV/AIDS,
    and how many teens give birth.
        Despite recent funding increases secured through your leadership,
    NCHS continues to feel the effects of long-term underinvestment,
    forcing the agency to eliminate or further postpone the collection of
    such vital information to the point where key data users now question
    whether NCHS itself is in good health. Years of flat funding and budget
    shortfalls forced the elimination of data collection and quality
    control efforts, threaten the collection of vital statistics, stymied
    the adoption of electronic systems, and limited the agency's ability to
    modernize surveys to reflect changes in demography, geography, and
    health delivery.
        The Coalition joins the Friends of NCHS--a coalition of more than
    250 health professional, research, consumer, industry, and employer
    organizations that support the agency--in recommending a base funding
    level of $137.5 million in fiscal year 2010 to ensure uninterrupted
    collection of vital statistics; restore other important data collection
    and analysis initiatives; to revise, pretest, and plan data collection
    activities for future calendar years, and modernize its systems to
    increase efficiency, interoperability, and security. In addition, we
    respectfully request that you provide NCHS $15 million in one-time
    funding to support the States and territories as they implement the
    2003 birth certificates and electronic systems to collect birth data in
    real-time to facilitate public health monitoring and planning. Future
    supplemental funding will be required to implement the 2003 death
    certificates in all States and complete the automation of data
    collection. The Coalition greatly appreciates that through your
    leadership early versions of the American Recovery and Reinvestment Act
    in the House and Senate included $40 million for this infrastructure
    development; we were disappointed that it had to be eliminated from the
    final package.
        While significant funding has been provided to improve the public
    health system's capacity to respond to a terrorist attack or a public
    health crisis such as pandemic flu, insufficient funding has been
    provided to support research that evaluates the effectiveness of our
    preparedness interventions and seeks to improve the delivery of public
    health services. For example, how cost effective are public health and
    prevention programs? How can the medical care and public health
    delivery systems be better linked? CDC's important Public Health
    Research program and Prevention Research Centers-a network of academic
    health centers that conduct public health research-have been flat
    funded since fiscal year 2006 at levels of $31 million and $29 million,
    respectively. The Coalition requests at least $35 million for Public
    Health Research and at least $33 million for Prevention Research
    Centers in fiscal year 2010. The programs seek ways to development,
    translate, and disseminate research to address obesity, diabetes, and
    heart disease, healthy aging and youth development, cancer risk, and
    health disparities.
                centers for medicare and medicaid services (cms)
        Steady funding decreases for the Office of Research, Development
    and Information, together with an increasingly earmarked budget, has
    hindered CMS' ability to meet its statutory requirements and conduct
    new research to strengthen our public insurance programs--including
    Medicare, Medicaid, and SCHIP--which together provide coverage to
    nearly 100 million Americans and comprise 45 percent of America's total
    health expenditures. At a time when these programs pose significant
    budget challenges for both the Federal and State governments, it is
    critical that we adequately fund research to evaluate these programs'
    efficiency and effectiveness, and seek ways to manage their projected
    spending growth.
        The Coalition supports increasing CMS's discretionary research and
    development budget from $31 million in fiscal year 2009 to a base
    fiscal year 2010 funding level of $45 million--in addition to funding
    for programmatic earmarks--as a critical down payment to help CMS
    recover lost resources and restore research to evaluate their programs,
    analyze pay for performance and other tools to update payment
    methodologies, and to further refine service delivery methods.
                                      nih
        The NIH reported that it spent $743 million on health services
    research in fiscal year 2008--roughly 2.9 percent of its entire
    budget--making it the largest Federal sponsor of health services
    research. For fiscal year 2010, the Coalition recommends a health
    services research base funding level of at least $940 million--2.9
    percent of the $32 billion the broader health community is seeking for
    NIH in fiscal year 2010. We encourage NIH to increase the proportion of
    their overall funding that goes to health services research from 2.9 to
    5 percent to assure that discoveries from clinical trials are
    effectively translated into health services. We also encourage NIH to
    foster greater coordination of its health services research investment
    across its Institutes.
        In conclusion, the accomplishments of health services research
    would not be possible without the leadership and support of this
    subcommittee. As you know, the best healthcare decisions are based on
    relevant data and scientific evidence. At a time when you, your
    congressional colleagues, and members of the new administration are
    considering major health reform including ways to get more value for
    current expenditures, health services research and health data are
    needed more than ever to yield better information and lead to improved
    quality, accessibility, and affordability. We urge the subcommittee to
    accept our fiscal year 2010 funding recommendations for the Federal
    agencies funding health services research and health data.
                                     ______

         Prepared Statement of the Coalition of Northeastern Governors
        The Coalition of Northeastern Governors (CONEG) is pleased to
    submit this testimony for the record to the Senate Subcommittee on
    Labor, Health and Human Services, and Education, and Related Agencies
    regarding fiscal year 2010 appropriations for the Low Income Home
    Energy Assistance Program (LIHEAP).
        The governors appreciate the subcommittee's continued support for
    the LIHEAP program, and we thank you for providing the full authorized
    amount of $5.1 billion in fiscal year 2009 LIHEAP funding. The
    governors recognize the considerable fiscal challenges facing the
    subcommittee this year. However, we urge you to maintain the $5.1
    billion level in regular fiscal year 2010 LIHEAP block grant funding as
    well as contingency funds to address unforeseen energy emergencies.
        LIHEAP is a vital safety net for millions of vulnerable low-income
    households--the elderly and disabled living on fixed incomes, the
    working poor, and families with young children. The highest level of
    LIHEAP assistance is provided to households with the lowest incomes
    that pay a high proportion of their income (up to 17 percent) for home
    energy. A December 2007 study by the Oak Ridge National Laboratory
    found that, in recent years, the increase in the cost of home energy
    has far outpaced the rate of inflation and the increase in household
    income. Even with continued belt-tightening, there is just no room in
    the budget of these low-income households to pay for increasing energy
    bills.
        The current economic crisis exerts additional pressures on these
    households, making energy assistance more important now than ever
    before. In 2007, even before the current recession took hold, 8.7
    million residential consumers had their electricity or natural gas
    service terminated for failing to pay their bills, according to a
    survey by the National Association of Regulatory Utility Commissioners
    (December 2008). The same survey found at the end of the 2007-2008
    winter heating season, the number of electricity and natural gas
    residential households with past due accounts had jumped to almost 40
    million consumers, and represented nearly $8.7 billion in past due
    accounts.
        According to the National Energy Assistance Directors' Association,
    the $5.1 billion in fiscal year 2009 LIHEAP funding makes it possible
    for States to serve approximately 7.3 million households this year.
    This record number represents a 25 percent increase more than last year
    and reflects the increased unemployment rate and rise in home energy
    costs. Yet this is only a small portion of the LIHEAP-eligible
    households in today's economy.
        If the $5.1 billion level of LIHEAP funding is not sustained in
    fiscal year 2010, States nationwide will be forced to eliminate more
    than 1.5 million families from the program in order to maintain some of
    the purchasing power of the LIHEAP grant for the program's poorest
    families, or to reduce benefit levels overall. States in the Northeast
    already incorporate various administrative strategies that allow them
    to deliver maximum program dollars to households in need. These include
    using uniform application forms to determine program eligibility,
    establishing a one-stop shopping approach for the delivery of LIHEAP
    and related programs, sharing administrative costs with other programs,
    and using mail recertification. Opportunities to further reduce LIHEAP
    administrative costs are limited, since they are already among the
    lowest of the human service programs.
        In spite of these State efforts to stretch Federal and State LIHEAP
    dollars, the need for the program is far too great. Increased,
    predictable and timely Federal funding is vital for LIHEAP to assist
    the Nation's vulnerable, low-income households faced with exorbitant
    home energy bills. The CONEG governors urge the Subcommittee to provide
    $5.1 billion in regular block grant funding for LIHEAP in fiscal year
    2010 as well as contingency funds to address unforeseen energy
    emergencies. This sustained level of funding will help States to
    provide meaningful assistance to households in need as millions of low-
    income citizen's struggle with simply unaffordable home energy bills.
    LIHEAP can continue to provide a vital safety net protecting these
    vulnerable households from the potentially deadly heat and cold.
                                     ______

           Prepared Statement of the Council on Social Work Education
        On behalf of the Council on Social Work Education (CSWE), I am
    pleased to offer this written testimony to the Senate Appropriations
    Subcommittee on Labor, Health and Human Services, and Education, and
    Related Agencies for inclusion in the official subcommittee record. I
    will focus my testimony on the importance of fostering a skilled,
    sustainable and diverse social work workforce through training and
    financial support programs at the Department of Health and Human
    Services and the Department of Education.
        CSWE is a nonprofit national association representing more than
    3,000 individual members as well as 650 graduate and undergraduate
    programs of professional social work education. Founded in 1952, this
    partnership of educational and professional institutions, social
    welfare agencies, and private citizens is recognized by the Council for
    Higher Education Accreditation as the sole accrediting agency for
    social work education in the United States. Social work education
    focuses students on leadership and direct practice roles helping
    individuals, families, groups, and communities by creating new
    opportunities that empower people to be productive, contributing
    members of their communities.
        Vulnerable populations from all walks of life--defined here as
    children and adults with physical or mental disabilities, those living
    in poverty, trauma victims, aging individuals, returning veterans,
    individuals under stress or facing coping challenges both temporary and
    permanent, and segments of society needing assistance to adjust to
    changing circumstances or overcome injustices--are faced with hurdles
    which for some cannot be overcome alone. Social workers help vulnerable
    populations in society be as healthy and productive as possible by
    working with them to navigate societal and personal challenges. Social
    workers are employed in schools, hospitals, VA facilities,
    rehabilitation centers, social service locations, child welfare
    organizations, assisted living centers, nursing homes, and faith-based
    organizations.
         training opportunities and debt load relief for social workers
        Recruitment and retention pose the most significant challenge to
    the success of the social work profession. This is true across all
    sectors (public and private), at all levels (from BSW to the doctoral
    level), and in all fields of practice (child welfare, public health,
    mental health, geriatrics, veterans, etc.).
        The Nation needs a workforce that is skilled, diverse, and able to
    keep pace with demand. In 2004, the Bureau of Labor Statistics (BLS)
    reported that by 2012 a total of 209,000 social workers will be needed
    in the fields of child, family, and school social work; medical and
    public health social work; and mental health and substance abuse social
    work. In 2006, the BLS estimated there would be a total of 258,000 job
    openings for social workers due to growth and net replacement between
    2006 and 2016 in the same fields.
        While recruitment and retention can be a significant challenge for
    many professions, especially those dealing with public health and the
    delivery of social services, the problem is exceptionally widespread
    for social work. Recruitment into the social work profession faces many
    obstacles, the most prevalent being low wages.
        As we look toward reforming the American healthcare system, we must
    consider the needs of the workforce that will be responsible for
    ensuring the health of the population. The recommendations for fiscal
    year 2010 would help to ensure that we are fostering a sustainable,
    skilled, and diverse workforce that will be able to keep up with the
    increasing demand.
                 department of health and human services (hhs)
        The various agencies within the HHS provide training and fellowship
    opportunities for social workers, as well as loan forgiveness programs
    to help social workers stay in the field. CSWE urges the subcommittee's
    support of the following HHS programs; this is not an exhaustive list:
        Minority Fellowship Program, Substance Abuse and Mental Health
    Services Administration (SAMHSA).--The goal of the SAMHSA Minority
    Fellowship Program (MFP), which is administered through the Center for
    Mental Health Services, is to achieve greater numbers of minority
    doctoral students preparing for leadership roles in the mental health
    and substance abuse field. According to SAMHSA, ``Minorities make up
    approximately one-fourth of the population, but only about 10 percent
    of mental health providers are ethnic minorities.'' CSWE has been a
    grantee of this critical program for years, administering funds to
    exceptional minority social work students. Together with a program at
    the National Institute of Mental Health (NIMH), CSWE has supported more
    than 500 minority fellows since the program's inception, with about
    two-thirds of those students having gone on to receive their doctoral
    degrees. For fiscal year 2010, CSWE urges the subcommittee to fund the
    SAMHSA Minority Fellowship Program at $7.5 million. This program has
    suffered from flat and declining budgets over the last several years.
    Thankfully, due to congressional support, it has been restored year
    after year, despite efforts by the Bush administration to cancel it.
    President Obama's fiscal year 2010 budget request includes level
    funding for the MFP at about $4 million. Funding the MFP at $7.5
    million would directly encourage more social workers of minority
    background to pursue doctoral degrees in mental health and substance
    abuse and will turnout minority mental health professionals equipped to
    provide culturally competent, accessible mental health and substance
    abuse services to diverse populations.
        Institutional Research Training Program in Social Work (T32),
    NIMH.--NIMH within the National Institutes of Health (NIH) initiated a
    training program in the 1970s that sought to increase the number of
    minority doctoral students focusing their research in mental health.
    Like the SAMHSA program mentioned above, CSWE has ably administered a
    grant from NIMH for many years, which provides mentored training
    opportunities to minority social work researchers. The social work
    profession depends on culturally competent and culturally relevant
    research to assess the circumstances facing vulnerable populations and
    the needs of those populations to succeed in their circumstances;
    evaluate the accessibility to and effectiveness of existing social
    services; and determine best practices for social work educators and
    practitioners for serving the community. While this program has been
    successful in enhancing diversity among social workers conducting
    mental health research and has allowed more underrepresented social
    work researchers to be brought into the fold as NIH investigators, NIMH
    recently announced its plan to cancel the program in 2010 and
    transition the funds to support the traditional, nondiversity-focused
    T32 training program at NIMH. CSWE is very concerned about the
    implications of this decision, both on the diversity of researchers at
    NIMH and what we feel could lead to an absence of social work research
    at NIMH. We hope the subcommittee will encourage NIMH to take the
    necessary steps to enhance diversity of the NIH/NIMH grant pool and
    express to NIMH the value and importance of social work research to the
    study of mental health.
        Title VII Health Professions Programs, Health Resources and
    Services Administration (HRSA).--The title VII health professions
    programs at HRSA provide financial support for education and
    development of the healthcare workforce. The emphasis of these programs
    is on improving the quality, diversity, and geographic distribution of
    the health professions workforce, and is currently the only Federal
    program to do so. These programs provide loans, loan guarantees and
    scholarships to students and grants to institutions of higher education
    and nonprofit organizations to help build and maintain a robust
    healthcare workforce. Social work students and practioners are eligible
    for title VII funding. We thank you for recognizing the value of these
    programs by providing $200 million in stimulus funding to the title VII
    and title VIII (nursing) programs in the American Recovery and
    Reinvestment Act of 2009 (Public Law 111-5). CSWE urges the
    subcommittee to provide $330 million for the title VII health
    professions programs for fiscal year 2010.
        Loan Repayment Program, Indian Health Service (IHS).--The Loan
    Repayment Program at IHS offers repayment of health professions
    educational loans in exchange for a commitment to work at an IHS or
    other Indian health program priority site for a minimum of 2 years.
    Social workers are eligible to participate in this program, as defined
    in section 4(n) of the Indian Health Care Improvement Act (Public Law
    94-437). With appropriate funding, this program can serve as an
    effective recruitment tool. However, the program has been grossly
    underfunded for a number of years. For example, last year IHS denied
    funding to 231 healthcare professionals already working in IHS as well
    as 95 recruits, due to a lack of resources. CSWE, a member of the
    Friends of Indian Health Coalition, urges the subcommittee to provide
    an additional $18.5 million above fiscal year 2009 funding for the IHS
    Loan Repayment Program for fiscal year 2010 in order to address the
    critical recruitment needs of the agency.
                            department of education
        The last few years have seen the creation of a number of loan
    forgiveness and training programs for which social work would benefit,
    if adequately funded. CSWE urges the subcommittee to support the
    following programs at the Department of Education:
        Graduate Assistance in Areas of National Need (GAANN) Program.--The
    GAANN program provides graduate traineeships in critical fields of
    study. Currently, social work is not defined as an area of national
    need for this program; however it was recognized by Congress as an area
    of national need in the Higher Education Opportunity Act of 2008 as
    discussed below. We are hopeful that the Department of Education will
    recognize the importance of including social work in the GAANN program
    in future years. Inclusion of social work would help to significantly
    enhance graduate education in social work, which is critically needed
    in the country's efforts to foster a sustainable health professions
    workforce. CSWE supports a budget of at least $41 million for GAANN in
    fiscal year 2010. However, if social work were to be added by the
    Department as a new area of national need, additional resources would
    need to be provided so as not to take funding away from the already
    determined areas of national need.
        Loan Forgiveness for Service in Areas of National Need Program.--
    The Higher Education Opportunity Act of 2008 (Public Law 110-315)
    created the Loan Forgiveness for Service in Areas of National Need
    program. This program applies to full-time workers who are employed in
    areas of national need, such as social workers working in public or
    private child welfare agencies or mental health professionals with at
    least a master's degree in social work. CSWE urges full funding for
    this new program for fiscal year 2010.
        In addition to these discretionary programs, a number of mandatory
    programs were created in the College Cost Reduction Act of 2007 (Public
    Law 110-84). We look forward to working with the Department of
    Education as these programs are implemented. Among the programs that
    include social work education are:
        Income-based Repayment (IBR)Program.--IBR program will begin
    operation in July 2009. This new program caps Federal student loan
    payments at a reasonable percentage of income and cancels most
    remaining balances of student loans after 25 years. CSWE will be
    monitoring the implementation of this new program to assess the extent
    to which it is assisting social workers address their debt load
    reduction needs.
        Income Contingent Payment for Public Sector Employment Program
    (Public Service Loan Forgiveness).--The College Cost Reduction Act of
    2007 revised the Income Contingent Payment for Public Sector Employment
    program, which previously allowed a borrower who works in public
    service to pay their loans more than 25 years after which their debt
    would be forgiven. The law now states that public service workers
    working for an eligible nonprofit can cancel their loans after 10 years
    of service for loans taken out after October 1, 2007. Like the IBR
    program, CSWE plans to monitor the implementation of this program to
    assess its success in assisting social workers address high educational
    debt load.
        We hope the subcommittee will take these points into consideration
    as you move forward in the fiscal year 2010 appropriations process.
                                     ______

                Prepared Statement of Central Technical Services
                summary of recommendations for fiscal year 2010
        Continue the Commitment to Providing the National Institutes of
    Health (NIH) and the National Library of Medicine (NLM) with meaningful
    funding increases on an annual basis. Continue to support and defend
    the NIH's public access policy, which requires that all final, peer-
    reviewed manuscripts are made available through NLM's pubmed central
    database within 12 months of publication. Continue to support the
    medical library community's important role in NLM's outreach,
    telemedicine, disaster preparedness and health information technology
    (health IT) initiatives.
        On behalf of the Medical Library Association (MLA) and the
    Association of Academic Health Sciences Libraries (AAHSL), thank you
    for the opportunity to present testimony regarding fiscal year 2010
    appropriations for the NLM.
        MLA is a nonprofit, educational organization with more than 4,000
    health sciences information professional members worldwide. Founded in
    1898, MLA provides lifelong educational opportunities, supports a
    knowledge base of health information research, and works with a global
    network of partners to promote the importance of quality information
    for improved health to the healthcare community and the public.
        AAHSL is comprised of the directors of the libraries of 142
    accredited American and Canadian medical schools belonging to the
    Association of American Medical Colleges. AAHSL's goals are to promote
    excellence in academic health sciences libraries and to ensure that the
    next generation of health professionals is trained in information-
    seeking skills that enhance the quality of healthcare delivery.
        Together, MLA and AAHSL address health information issues and
    legislative matters of importance through a joint legislative task
    force and a Government Relations Committee.
               the importance of annual funding increases for nlm
        I thank the subcommittee for its leadership and hard work on the
    American Recovery and Reinvestment Act of 2009 (Public Law 111-5), the
    economic stimulus package. As you know, the important mission of NIH
    and the important role that NLM plays in fulfilling that mission were
    hampered by past-years of near level funding. The investment in NIH and
    NLM provided by the stimulus package will not only create meaningful
    employment opportunities, it will also revitalize NLM's programs, which
    are focused on improving the public health.
        We are pleased that the recently passed fiscal year 2009 omnibus
    appropriations package contains funding increases for NIH and NLM that
    will bolster their baseline budgets. We hope that this funding is an
    indication of the subcommittee's intention to provide annual,
    meaningful increases for NIH and NLM in the coming years.
        I am confident that the recovery funding and the fiscal year 2009
    budget increases will stimulate the economy, stimulate biomedical
    research, and in the case of NLM, improve the dissemination of health
    information to researchers, practitioners, and the general public.
    Moving forward, it will be critical to provide NIH's baseline budget
    with the funding increases necessary to allow the short-term growth
    generated by the stimulus to become a long-term investment towards
    improved public health through bolstered health information programs.
    Building and Facility Needs
        NLM has had tremendous growth in its basic functions related to the
    acquisition, organization, and preservation of an ever-expanding
    collection of biomedical literature. It also has been assigned a
    growing set of set of responsibilities related to the collection,
    management, and dissemination genomic information, clinical trials
    information, and disaster preparedness and response. As a result, NLM
    faces a serious shortage of space, for staff, library materials, and
    information systems. Digital archiving--once thought to be a solution
    to the problem of housing physical collections--has only added to the
    challenge, as materials must often be stored in multiple formats
    (physical and digital) and as new digital resources demand increasing
    amounts of storage space. As a result, the space needed for computing
    facilities has also grown. In order for NLM to continue its mission as
    the world's premier biomedical library, a new facility is urgently
    needed. The NLM Board of Regents has assigned the highest priority to
    supporting the acquisition of a new facility. Further, Senate Report
    108-345 that accompanied the fiscal year 2005 appropriations bill
    acknowledged that the design for the new research facility at NLM had
    been completed, and the subcommittee urged NIH to assign a high
    priority to this construction project so that the information-handling
    capabilities and biomedical research are not jeopardized.
    The Growing Demand for NLM's Basic Services
        As the world's foremost digital library and knowledge repository in
    the health sciences, NLM provides the critical infrastructure in the
    form of data repositories and integrated services such as GenBank and
    PubMed that are helping to revolutionize medicine and advance science
    to the next important era--individualized medicine based on an
    individual's unique genetic differences.
        NLM's clinical trials database, ClinicalTrials.gov, which was
    launched in February 2000 and lists registration information on more
    than 70,000 U.S. and international trials for a wide range of diseases,
    also now serves as a repository for summary results information. The
    expanded system serves not only as a free, but invaluable resource for
    patients and families who are interested in participating in trials of
    new treatments for a wide range of diseases and conditions, but also as
    an important source of information for clinicians interested in
    understanding new treatments and for those involved in evidence-based
    medicine and comparative effectiveness research.
        As the world's largest and most comprehensive medical library,
    services based on NLM's traditional and electronic collections continue
    to steadily increase each year.
        These collections stand at more than 11.4 million items--books,
    journals, technical reports, manuscripts, microfilms, photographs, and
    images. By selecting, organizing and ensuring permanent access to
    health science information in all formats, NLM is ensuring the
    availability of this information for future generations, making it
    accessible to all Americans, irrespective of geography or ability to
    pay, and ensuring that each citizen can make the best, most-informed
    decisions about their healthcare. Without NLM our Nation's medical
    libraries would be unable to provide the quality information services
    that our Nation's health professionals, educators, researchers, and
    patients have all come to expect.
                              defend public access
        The Appropriations Committee has shown unprecedented foresight and
    leadership by using the annual spending bills as the vehicle to
    establish a public access policy at the NIH. The current policy
    requires that all NIH-funded researchers deposit their final, peer-
    reviewed manuscripts in NLM's PubMed Central database within 12 months
    of publication. This policy will not only help NIH better manage its
    portfolio of research, but will contribute to the development of a
    biomedical informatics infrastructure that will stimulate further
    discovery by enabling a much greater and tighter interlinking of
    information from NLM's wide-ranging set of databases. It also
    contributes to outreach initiatives by providing much-needed access to
    health literature to those without direct access to medical libraries.
    While the fiscal year 2009 omnibus package made this policy permanent
    moving forward, challenges remain and we urge the subcommittee to
    continue to defend this policy.
        support and encourage nlm partnerships with the medical library
                                   community
    Outreach and Education
        NLM's outreach programs are of particular interest to both MLA and
    AAHSL. These activities are designed to educate medical librarians,
    health professionals and the general public about NLM's services. NLM
    has taken a leadership role in promoting educational outreach aimed at
    public libraries, secondary schools, senior centers and other consumer-
    based settings. Furthermore, NLM's emphasis on outreach to underserved
    populations assists the effort to reduce health disparities among large
    sections of the American public. One example of NLM's leadership is the
    ``Partners in Information Access'' program, which is designed to
    improve the access of local public health officials to information
    needed to prevent, identify and respond to public health threats. With
    nearly 6,000 members in communities across the country, the National
    Network of Libraries of Medicine (NNLM) is well-positioned to ensure
    that every public health worker has electronic health information
    services that can protect the public's health.
        With help from Congress, NLM, NIH and the Friends of NLM, launched
    NIH MedlinePlus Magazine in September 2006. This quarterly publication
    is distributed in doctors' waiting rooms, and provides the public with
    access to high-quality, easily understood health information.
    Collaborating with the National Alliance for Hispanic Health, a Spanish
    version is now available, NIH MedlinePlus Salud. NLM also continues to
    work with medical librarians and health professionals to encourage
    doctors to provide MedlinePlus ``information prescriptions'' to their
    patients. This initiative also encourages genetics counselors to
    prescribe the use of NLM's Genetic Home Reference Web site.
        ``Go Local'' is another exciting service that engages health
    sciences libraries and other local and State agencies in the creation
    of Web sites that link from MedlinePlus to relevant information on
    local pharmacies, hospitals, doctors, nursing homes, and other health
    and social services. In Iowa, for example, University of Iowa
    librarians developed an Iowa Go Local site that enables users to find
    local health resources by Iowa county or city. It allows Iowa citizens
    to link directly from a MedlinePlus health topic, for example asthma,
    to local services, such as clinics, pulmonary specialists, and support
    groups in the geographic area selected. By collecting such information
    in one place, Go Local also provides a platform for enhancing access to
    the information needed to prepare for and respond to disasters and
    emergencies.
        MLA and AAHSL applaud the success of NLM's outreach initiatives,
    particularly those initiatives that reach out to medical libraries and
    health consumers. We ask the subcommittee to encourage NLM to continue
    to coordinate its outreach activities with the medical library
    community in fiscal year 2010.
                      emergency preparedness and response
        MLA and AAHSL are pleased that NLM has established a Disaster
    Information Management Research Center to expand NLM's capacity to
    support disaster response and management initiatives, as recommended in
    the NLM Board of Regents Long Range Plan for 2006-2016. We ask the
    subcommittee to show its support for this initiative, which has a major
    objective of ensuring continuous access to health information and
    effective use of libraries and librarians when disasters occur.
    Following Hurricane Katrina, for example, NLM worked with health
    sciences libraries across the country to provide health professionals
    and the public with access to needed health and environmental
    information by: (1) quickly compiling web pages on toxic chemicals and
    environmental concerns; (2) rapidly providing funds, computers and
    communication services to assist librarians in the field who were
    restoring health information services to displaced clinicians and
    patients; and (3) rerouting interlibrary loan requests from the
    afflicted regions through the NNLM. Presently, libraries are a
    significant, but underutilized resource for community disaster planning
    and management efforts, which NLM can help to deploy. With assistance
    from its NNLM, NLM is working with health sciences libraries to develop
    continuity of operations and backup plans and is exploring the role
    that specially trained librarians--disaster information specialists--
    can play in providing information services to emergency personnel
    during a crisis. MLA and AAHSL see a clear role for NLM and the NNLM in
    the Nation's disaster preparedness and response activities.
                          health it and bioinformatics
        NLM has played a pivotal role in creating and nurturing the field
    of biomedical informatics. Not only has NLM developed key biomedical
    databases, but for nearly 35 years, NLM has supported informatics
    research and training and the application of advanced computing and
    informatics to biomedical research and healthcare delivery including a
    variety of telemedicine projects. Many of today's informatics leaders
    are graduates of NLM-funded informatics research programs at
    universities across the country. Many of the country's exemplary
    electronic health record systems benefited from NLM grant support.
        A leader in supporting, licensing, developing, and disseminating
    standard clinical terminologies for free U.S.-wide use (e.g., SNOMED),
    NLM works closely with the Office of the National Coordinator for
    Health Information Technology (ONCHIT) to promote the adoption of
    interoperable electronic records.
        MLA and AAHSL encourage the subcommittee to continue its strong
    support of NLM's medical informatics and genomic science initiatives,
    at a point when the linking of clinical and genetic data holds
    increasing promise for enhancing the diagnosis and treatment of
    disease. MLA and AAHSL also support health information technology
    initiatives in ONCHIT and the Agency for Healthcare Research and
    Quality that build upon initiatives housed at NLM.
                                     ______

                 Prepared Statement of the Close Up Foundation
        Mr. Chairman, my name is Timothy S. Davis, President and CEO of the
    Close Up Foundation and I submit this testimony in support of our $5
    million appropriations request for the Close Up Fellowship Program.
        Close Up Foundation is a nonprofit, nonpartisan civic education
    organization dedicated to the idea that, within a democracy, informed,
    active citizens are essential to a responsive Government. Close Up's
    mission is to inform, inspire, and empower students and their teachers
    to exercise their rights and accept the responsibilities of citizens in
    a democracy. Close Up's experiential methodology emphasizes that
    democracy is not a spectator sport, and provides young people with the
    knowledge and skills to participate in the democratic process. Our
    students are a diverse group--coming from every State and beyond and
    from all walks of life. More than 650,000 have graduated from our
    experiential programs.
        Three core principles of Close Up are: (1) family income should not
    be a barrier to a students' participation, (2) commitment to
    diversity--outreach should reach a broad cross section of young people,
    and (3) enrollment should be open to all students, not just student
    leaders or high academic achievers.
        The Close Up Fellowship Program provides financial assistance to
    economically disadvantaged students and their teachers to participate
    on week-long Close Up Washington civic education programs. The
    Fellowship Program, authorized in Federal law since 1972 and currently
    authorized under section 1504 of the No Child Left Behind Act, has been
    continuously funded by a Congressional appropriation, through a U.S.
    Department of Education grant, for more than 35 years. Close Up makes
    every effort to ensure the participation of students from rural, small
    town, and urban areas and gives special consideration to students with
    special educational needs, including students with disabilities, ethnic
    minority students, and students with migrant parents. Student
    fellowships recipients are selected by their schools and must qualify
    according to the income eligibility guidelines.
        As in most years, funding for the Close Up Fellowship Program was
    not included in the President's budget submitted to Congress. Close Up
    respectfully requests that Congress again include funding for this
    important program through the appropriations process. I also wish to
    address some of the arguments made by the administration for
    eliminating the Close Up Fellowship Program.
        The administration's claim that peer organizations of Close Up
    provide scholarships to participants without Federal assistance is
    misleading. The average family income of a Close Up Fellowship
    recipient is approximately $24,000. To the extent that other nonprofit
    civic education organizations claim to provide scholarships, they
    usually are provided only to high academic achievers and certainly not
    on the scale and volume provided by Close Up. None of these
    organizations reach the numbers of economically disadvantaged students
    and teachers from under-resourced schools as Close Up does. Twenty-five
    percent of Close Up participants each year receive fellowship support
    provided through a mix of Federal funds and contributions raised from
    private sources by the Close Up Foundation.
        Close Up is also concerned with the administration's statement that
    our private fundraising efforts would allow our civic education program
    to continue. The statement misses the point. The result of elimination
    of the Close Up Fellowship Program would immediately deny participation
    to deserving and diverse students who, but for the fellowship program,
    would be unable to attend. In turn, this would make Close Up's student
    composition dramatically less diverse. While Federal funding represents
    a small portion of Close Up's revenue, it is a critical portion of our
    funding that permits us to reach as many economically disadvantaged
    students as we do.
        Finally, the administration wrongly asserted that it had minimal
    evidence that Close Up had a positive impact on the participating
    students and teachers. Close Up measures impact in four principle ways:
        Qualitative Data (some of our findings include):
        --97 percent of teachers said the program helped their students
                understand the role of a citizen in a democracy; 94 percent
                of students agreed.
        --94 percent of teachers said the program helped their students
                understand current policy issues facing the United States;
                94 percent of students agreed.
        --91 percent of teachers said the program complements what they
                teach in school.
        --95 percent of students said the program helped them understand
                that other students have views other than their own.
        --78 percent of students said that the program inspired them to
                become more involved in activities in civic activities when
                they return home.
        Qualitatively Data:
        --Close Up conducts weekly focus groups with students and teachers
                about their program experience and its impact on their
                lives.
        --Close Up assembles anecdotal information from teachers regarding
                the performance of their students and their community
                action projects.
        College Credit:
        --The University of Virginia and the University of Indiana, after a
                comprehensive evaluation of the academic value of the Close
                Up civic education programs, grant the opportunity for
                Close Up participants to receive undergraduate credit
                (students) and graduate credit (teachers), respectively.
        Local Support:
        --Thousands of schools organize and fundraise each year to send
                their young people on a Close Up program. Approximately
                18,000 students and teachers participate annually.
        --Local education officials have concluded that Close Up is of such
                value as to permit students and teachers to sacrifice a
                week of school and absence from all of their classes to
                participate.
        --Many school systems contribute scarce budget dollars to help
                students attend while most others provide resources for
                substitute teachers.
        Close Up Fellowship recipients add diversity to the student body on
    Close Up programs. The fellowship program thus benefits not only the
    recipient but all Close Up student program participants.
        Close Up is grateful to the United States Congress for its long-
    standing support of the Close Up Fellowship Program through the
    appropriations process. Tens of thousands of young people have been
    able to participate on Close Up Washington civic education programs as
    a result of the Federal funding.
        Close Up's fiscal year 2010 request is based on its desire to
    significantly increase the number of economically disadvantaged young
    people who participate on Close Up Washington civic education programs.
    The funds, which assist the disadvantaged and provide seed money for
    at-risk schools and communities to participate on these life
    transforming programs, are more important now than ever. Given the
    current economic climate, it will be more challenging for communities
    to raise the necessary funds for participation on Close Up programs.
    The Federal funding bridges that gap and Close Up feels that with
    aggressive outreach into economically distressed communities we can
    continue to provide these experiences to our young people.
        Close Up's appropriations request reflects the increasing cost of
    providing these important Washington programs. The cost of airfare,
    accommodations, food and local transportation skyrocketed during the
    decade that Close Up Fellowship funding remained flat at just under
    $1.5 million. The increase in the appropriations amount to $1.942
    million in fiscal year 2008 has helped combat a small portion of those
    increased costs but still results in a sharp decrease in the number of
    economically disadvantaged students that Close Up has been able to
    serve. We believe that during hard economic times it is even more
    imperative for the Federal Government to invest in the civic education
    of young people. And, by investing in a Close Up education, the
    Government also supports the suffering transportation and hospitality
    economic sectors.
        Senators have the opportunity to meet with Close Up groups from
    their States during Close Up ``Capitol Hill Day''. They see the
    excitement and pride as our students gain the confidence to express
    their views on the public policy issues that most directly affect their
    lives. Through workshops, seminars and the experience of being in
    Washington, Close Up instills these students with the knowledge and
    skills to become active citizens in our democracy.
        Many of your constituents would not be able to participate in this
    life altering program without the benefit of the Close Up Fellowship
    Program. There is no better investment that we can make in our Nation's
    future than building educated and responsible citizens, one person at a
    time.
        Close Up respectfully requests that the Senate Appropriations
    Subcommittee on Labor, Health and Human Services, and Education, and
    Related Services appropriate $5 million for the Close Up Fellowship
    Program.
                                     ______

              Letter From the Digestive Disease National Coalition
                                          Washington, DC, May 22, 2009.
    Hon. Tom Harkin,
    Chairman, Subcommittee on Labor, Health and Human Services, and
            Education, and Related Agencies, Washington, DC.
    Hon. Thad Cochran,
    Ranking Member, Subcommittee on Labor, Health and Human Services, and
            Education, and Related Agencies, Washington, DC.
        Dear Senators Harkin and Cochran: Thank you very much for your
    continued leadership in advancing healthcare policy.
        The Digestive Disease National Coalition (DDNC) is an advocacy
    organization comprised of the major national voluntary and professional
    societies concerned with digestive diseases. The DDNC focuses on
    improving public policy related to digestive diseases and increasing
    public awareness with respect to the many diseases of the digestive
    system. The DDNC works cooperatively to improve access to and the
    quality of digestive disease healthcare in order to promote the best
    possible medical outcome and quality of life for current and future
    patients with digestive diseases.
        In this capacity, the DDNC applauds the long-range research agenda
    as stated in the March 2009 publication Opportunities and Challenges in
    Digestive Diseases Research: Recommendations of the National Commission
    on Digestive Diseases by the National Institute of Diabetes, and
    Digestive, and Kidney Diseases (NIDDK). The DDNC requests that the
    subcommittee consider the following recommendations for the fiscal year
    2010 Labor, Health and Human Services, and Education, and Related
    Agencies appropriations bill:
      --A 6.5 percent funding increase for the National Institutes of
            Health, with a proportional increase for the NIDDK; and
      --An increase of $75 million for the VA Medical and Prosthetic
            Research Program for a total of $555 million.
        Thank you for the opportunity to present the views of the digestive
    disease community. Please do not hesitate to contact me if there is any
    more information you would like us to provide for your consideration.
                Sincerely,
                                               Dr. Peter Banks,
                                                             President.
                                               Linda K. Aukett,
                                                                 Chair.
                                     ______

         Prepared Statement of the Dystonia Medical Research Foundation
                summary of recommendations for fiscal year 2010
        Provide a funding increase of at least 7 percent for the National
    Institutes of Health (NIH) and its Institutes and Centers.
        Urge the National Institute on Neurological Disorders and Stroke
    (NINDS), the National Institute on Deafness and Other Communication
    Disorders (NIDCD), and the National Eye Institute (NEI) to expand their
    research portfolios on dystonia.
        Urge the NIH Office of Rare Diseases (ORD) to explore opportunities
    to partner with the Dystonia Medical Research Foundation (DRMF) and
    advance dystonia research.
        Dystonia is a neurological movement disorder characterized by
    powerful and painful involuntary muscle spasms that cause the body to
    twist, repetitively jerk, and sustain postural deformities. There are
    several different variations of dystonia, including; focal dystonias,
    which affect specific parts of the body, and generalized dystonia,
    which affect many parts of the body at the same time. Some forms of
    dystonia are genetic and others are caused by injury or illness.
    Dystonia does not affect a person's consciousness or intellect, but is
    chronic and progressive. In North America alone, conservative estimates
    indicate that between 300,000 and 500,000 individuals suffer with
    dystonia. Currently, there is no known cure and treatment options
    remain limited.
        While the underlying mechanisms of dystonia remain a mystery and
    the onset of symptoms can occur for a number of reasons, two therapies
    have emerged with proven health benefits to the dystonia patient
    community. Botulinum toxin injections and deep brain stimulation have
    shown varying degrees of success, depending on the individual, in
    alleviating a dystonia patient's symptoms. More research is needed to
    fully understand how to combat and cure dystonia, and in the mean time,
    maintaining patient access to life-improving therapies remains
    critical.
                         deep brain stimulations (dbs)
        DBS is a surgical procedure that was originally developed to treat
    Parkinson's disease, but is now being applied to severe cases of
    dystonia. A neurostimulator, or brain pacemaker, is surgically
    implanted and delivers electrical stimulation to the areas of the brain
    that control movement. While the exact reasons for effectiveness are
    unknown, the electrical stimulation blocks abnormal nerve signals that
    cause abnormal muscle spasms and contractions.
        Since DBS was approved for use by dystonia patients in 2003, it has
    drastically improved the lives of many individuals. Results have ranged
    from quickly regaining the ability to walk and speak, to regaining
    complete control over ones body and returning to an independent life as
    an able-bodied person. DBS is currently used to treat severe cases of
    generalized dystonia, but its promising role in treating focal
    dystonias is being explored and requires continuous support. Surgical
    interventions are a crucial and active area of dystonia research and
    may continue to lead to the development of promising treatment options.
                   botulinum toxin injections (botox/myobloc)
        The introduction of botulinum toxin as a therapeutic tool in the
    late 1980s revolutionized the treatment of dystonia by offering a new,
    localized method to significantly relieve symptoms for many people.
    Botulinum toxin, a biological product, is injected into specific
    muscles where it acts to relax the muscles and reduce excessive muscle
    contractions.
        Botulinum toxin is derived from the bacterium Clostridium
    botulinum. It is a nerve ``blocker'' that binds to the nerves that lead
    to the muscle and prevents the release of acetylcholine, a
    neurotransmitter that activates muscle contractions. If the message is
    blocked, muscle spasms are significantly reduced or eliminated.
        Injections of botulinum toxin should only be performed by a
    physician who is trained to administer this treatment. The physician
    needs to know the clinical features and study the involuntary movements
    of the person being treated. The physician doing the treatment may
    palpate (touch) the muscles carefully, trying to ascertain which
    muscles are over-contracting and which muscles may be compensating. In
    some instances, such as in the treatment of laryngeal dystonia, a team
    approach including other specialists may be required.
        For selected areas of the body, and particularly when injecting
    muscles that are difficult or impossible to palpate, guidance using an
    electromyograph (EMG) may be necessary. For instance, when injecting
    the deep muscles of the jaw, neck, or vocal cords, an EMG-guided
    injection may improve precision since these muscles cannot be readily
    palpated. An EMG measures and records muscle activity and may help the
    physician locate overactive muscles.
        Injections into the overactive muscle are done with a small needle,
    with one to three injections per muscle. Discomfort at the site of
    injections is usually temporary, and a local anesthetic is sometimes
    used to minimize any discomfort associated with the injection. Many
    dystonia patients frequently rely on botulinum toxins injections to
    maintain their improved standard of living due to the fact that the
    benefits of the treatment peak in approximately 4 weeks and lasts just
    3 or 4 months. Currently, FDA-approved forms of botulinum toxin include
    Botox and Myobloc.
                                dystonia and nih
        Currently, three Institutes at NIH conduct medical research into
    dystonia. They are NINDS, NIDCD, and NEI.
        NINDS has released important Program Announcements in recent years
    to study the causes and mechanisms of dystonia. These awards cover a
    wide range of research areas, which included gene discovery, the
    genetics and genomics of dystonia, the development of animal models of
    primary and secondary dystonia, molecular and cellular studies
    inherited forms of dystonia, epidemiology studies, and brain imaging.
    DMRF often works with NINDS to support as much critical research as
    possible and advance understating of dystonia.
        NIDCD has funded many studies on brainstem systems and their role
    in spasmodic dysphonia. Spasmodic dysphonia is a form of focal
    dystonia, and involves involuntary spasms of the vocal cords causing
    interruptions of speech and affecting voice quality. Our understanding
    of spasmodic dysphonia has been greatly enhanced by research
    initiatives at NIDCD, like the brainstem systems studies.
        NEI focuses some of its resources on the study of blepharospasm.
    Blepharospasm is an abnormal, involuntary blinking of the eyelids from
    an unknown cause that is associated with abnormal function of the basal
    ganglion. The condition can progress to the point where facial spasms
    develop. Presently, NEI is conducting a study entitled, Mexiletine for
    the Treatment of Focal Dystonia and a Doxilr Blepharospasm Treatment
    Trial, both of which have the potential to significantly improve
    treatment options for blepharospasm patients.
        An emerging area of NIH that has the potential to stimulate
    important, new research into dystonia is ORD housed in the Office of
    the Director. ORD can facilitate research networks into certain rare
    conditions by pulling together resources housed at other NIH Institutes
    and Centers. Given the prevalence of dystonia, the DMRF would like to
    work more closely with ORD to stimulate and support new research
    opportunities.
        DMRF also supports many extramural researchers studying dystonia.
    Research includes: exploring improved clinical rating scales for
    dystonia, elevations of sensory motor training, utilizing Botox as a
    possible treatment for focal hand dystonia, characterization of
    abnormalities in sensory regions of the brain, treatments for spasmodic
    dysphonia, DBS (the direct electrical stimulation of specific brain
    targets), noninvasive transcranial brain stimulation, anatomy imaging
    of the effect of dystonia on brain activity, and exploring the link
    between laryngitis and spasmodic dysphonia.
        Recent years of near level-funding at NIH have negatively impacted
    the mission of its Institutes and Centers. For this reason, DMRF
    applauds initiatives like Senator Arlen Specter's (D-PA) successful
    effort to provide NIH with $10.4 billion in stimulus funds. IFFGD urges
    this subcommittee to show strong leadership in pursuing substantial
    funding increase through the regular appropriations process in fiscal
    year 2010.
        For fiscal year 2010, DMRF recommends a funding increase of at
    least 7 percent for NIH and its Institutes and Centers.
        For fiscal year 2010, DMRF recommends that NINDS, NIDCD, and NEI be
    urged to increase their research activities regarding dystonia and
    partner with voluntary health organizations to promote dystonia
    research and awareness.
        For fiscal year 2010, DMRF asks the subcommittee to urge ORD to
    consider ways it can partner with DMRF and support dystonia research.
                                      dmrf
        DMRF was founded more than 30 years ago and has been a membership-
    driven organization since 1993. Since our inception, the goals of DMRF
    have remained: to advance research for more effective treatments of
    dystonia and ultimately find a cure; to promote awareness and
    education; and support the needs and well being of affected individuals
    and their families.
        Thank you for the opportunity to present the views of the dystonia
    community.
                                     ______

        Prepared Statement of the Federation of American Societies for
                              Experimental Biology
        The Federation of American Societies for Experimental Biology
    (FASEB), respectfully requests a funding increase of at least 7 percent
    above the fiscal year 2009 baseline level for the National Institutes
    of Health (NIH) in fiscal year 2010. This funding level is an important
    step toward President Obama's campaign pledge to double funding for
    basic research over 10 years and is necessary to maintain both the
    existing and future scientific infrastructure. We are in a crucial time
    for science in the United States. After years of stagnant funding for
    research, Congress has recently made significant new investments in
    NIH. The scientists and researchers represented by FASEB are sincerely
    grateful to Congress for your faith in the research community and your
    generosity in providing the resources that are essential for progress
    in science.
        As a Federation of 22 professional scientific societies, FASEB
    represents nearly 90,000 life scientists, making us the largest
    coalition of biomedical research associations in the Nation. FASEB's
    mission is to advance health and welfare by promoting progress and
    education in biological and biomedical sciences, including the research
    funded by NIH, through service to its member societies and
    collaborative advocacy. FASEB enhances the ability of biomedical and
    life scientists to improve--through their research--the health, well-
    being, and productivity of all people.
        We especially thank and commend Congress for including the
    extraordinary investment in medical research at NIH that was included
    as part of in the American Recovery and Reinvestment Act (ARRA, Public
    Law 111-5) as well as the $938 million increase in NIH funding in the
    Omnibus Appropriations Act for fiscal year 2009 (Public Law 111-8). In
    particular, we are deeply grateful to the chairman and this
    subcommittee for your long-standing leadership in support of NIH. These
    are difficult times for our Nation and for people all around the globe,
    but the affirmation of science is the key to a better future is a
    strategic step forward.
        The recent history of the NIH budget has hindered scientific
    discovery and limited the capacity of a key engine for today's
    innovation-based economy. The additional funding in the ARRA and the
    fiscal year 2009 omnibus are critical first steps to returning the NIH
    to a course for even greater discovery. These investments give
    patients, their families and researchers renewed hope for the future,
    and will help ensure the success of America's medical research
    enterprise and leadership.
        The funding increases in the ARRA and the fiscal year 2009 omnibus
    will provide an immediate infusion of funds into the Nation's proven
    and highly competitive medical research enterprise to sustain the
    pursuit of improved diagnostics, better prevention strategies and new
    treatments for many devastating and costly diseases as well as support
    innovative research ideas, state-of-the-art scientific facilities and
    instrumentation, and the scientists, technicians, laboratory personnel,
    and administrators necessary to maintain the enterprise. These funds
    will are also reinvigorating this Nation's ability to produce the human
    and intellectual capital that will continue to drive scientific
    discovery, transform health, and improve the quality of life for all
    Americans. Moreover, we see this as the first step in renewing a
    national commitment to sustained, predictable growth in NIH funding,
    which we believe is an essential element in restoring and sustaining
    both national and local economic growth and vitality as well as
    maintaining this Nation's prominence as the world leader in medical
    research.
        As a result of this subcommittee's prior investment in NIH, we have
    made critical advances in understanding basic science, saved and
    improved the lives of millions of Americans and provided doctors with
    tools to prevent and treat costly and devastating diseases including:
      --Cardiovascular Disease.--New results from multiple studies provided
            the strongest evidence to date that a simple blood test for
            high-sensitivity C-reactive protein (hsCRP), whose
            characterization was funded by NIH, is a useful marker for
            cardiovascular disease. Furthermore, scientists have discovered
            that a daily dose of a commonly used statin, rosuvastatin
            (Crestor), reduced the risk of heart attack, stroke, and death
            by nearly half (44 percent) in individuals with high levels of
            hsCRP but with normal or low levels of low density lipoprotein
            (LDL), the so-called ``bad cholesterol.'' These developments
            show great promise in helping clinicians better identify and
            treat individuals at risk for cardiovascular disease--
            potentially saving millions more lives.
      --Cancer.--For the first time in a decade, incidence rates for all
            cancers combined are decreasing, driven largely by declines in
            some of the most common types of cancer, including breast
            cancer (2.2 percent decline among women) and prostate cancer
            (4.4 percent decline). Death rates declined for 10 of the top
            15 causes of cancer death among both men and women.
      --Alzheimer's.--Researchers isolated a toxic substance that appears
            to be a key to understanding Alzheimer's disease, suggesting a
            possible new target for developing drug therapies to combat the
            irreversible and progressive disorder. In addition, further
            insights into the early stages of Alzheimer's may answer
            questions not only about the disease, but also about age-
            related memory impairments.
      --Type 2 Diabetes.--An international team that included NIH-funded
            scientists identified six new genetic variants associated with
            increased risk of type 2 diabetes. By pinpointing particular
            pathways involved in diabetes risk, this discovery can empower
            new approaches to understanding environmental influences and to
            the development of better, more precisely targeted drugs.
         investment in nih is critical to taking advantage of emerging
                            scientific opportunities
        Prior investment in NIH has begun to unlock the secrets of the
    human genome and allowed scientists to gain new insight into how
    disease works at the most basic levels within our bodies. Scientists
    are working tirelessly to translate research results into interventions
    for our most debilitating medical conditions. NIH also serves an
    invaluable role in communicating research findings to patients and
    their families, healthcare providers, and the general public in
    critical areas such as increasing knowledge about infectious diseases,
    improving cognitive health, and reducing health disparities.
               the consequences of stagnant funding for research
        The re-emergence of previously eradicated diseases such as mumps,
    the development of new health threats, a rapidly aging population, and
    significant increases in longevity lends a sense of urgency to the need
    to expedite scientific discovery. Yet even as our need to prevent
    disease becomes greater and the opportunities to succeed become more
    numerous, our national commitment to medical research has stagnated:
      --``Success rates'' dropped to an estimated 18 percent in fiscal year
            2009. This means that more than 80 percent of the highly
            qualified, peer-reviewed research proposals go unfunded. With
            every unfunded idea, we risk missing or delaying critical
            discoveries leading to therapies for our most debilitating
            health conditions.
      --The competition for funding is coming at a time when both the
            interest in careers in the science field and the number of
            newly trained researchers entering the workforce is increasing.
            Doctorates in the critical fields of engineering and biological
            sciences increased 10 percent and 11 percent respectively, in 1
            year.\1\
    ---------------------------------------------------------------------------
        \1\ Council of Graduate Schools. 2008. Graduate Enrollment and
    Degrees: 1997-2007. http://www.cgsnet.org/portals/0/pdf/N_pr_ED2007.pdf
    ---------------------------------------------------------------------------
      --The medical schools, teaching hospitals, universities, and research
            institutes where NIH research takes place are among the largest
            employers in their respective communities. In fiscal year 2007,
            NIH grants and contracts created and supported more than
            350,000 jobs that generated wages in excess of $18 billion in
            the 50 States.\2\
    ---------------------------------------------------------------------------
        \2\ Families USA. 2008. In your own backyard: How NIH funding helps
    your state's economy. http://www.familiesusa.org/assets/pdfs/global-
    health/in-your-own-backyard.pdf
    ---------------------------------------------------------------------------
         the importance of sustained, predictable funding for research
        The research engine needs a predictable, sustained investment in
    science to maximize our return on investment. The discovery process--
    while it produces tremendous value--often takes a lengthy and
    unpredictable path. Recent experience has demonstrated how cyclical
    periods of rapid funding growth followed by periods of stagnation is
    disruptive to training, to careers, long-range projects, and ultimately
    to progress. NIH needs sustainable and predictable budget growth to
    achieve the full promise of medical research to improve the health and
    longevity of all Americans. We must ensure that after the stimulus
    money is spent we do not have to dismantle our newly built capacity and
    terminate valuable, on-going research.
        The fiscal year 2009 omnibus and the ARRA provided $38.5 billion
    for NIH to provide more than 16,000 new research grants for live-saving
    research into diseases such as cancer, diabetes, and Alzheimer's.
    Keeping up with the rising cost of medical research in the 2010
    appropriations will help NIH begin to prepare for the ``post-stimulus''
    era. In 2011 and beyond we need to make sure that the total funding
    available to NIH does not decline and that we can resume a steady,
    sustainable growth that will enable us to complete the President's
    vision of doubling our investment in basic research. Consistent with
    the President's proposal, we respectfully urge this subcommittee to
    increase funding for NIH in fiscal year 2010 by at least 7 percent more
    than the fiscal year 2009 level.
        The Federal commitment to biomedical research is profoundly
    transforming medical practice, preventing disease, and creating better
    therapies but additional resources are needed to pursue the historic
    level of scientific opportunity that is available today. We recognize
    this subcommittee has the especially difficult task of providing
    funding for a wide range of critical human service programs and thank
    you for recognizing that prosperity and quality of life are
    increasingly shaped by investments in science and technology.
                                     ______

    Prepared Statement of the Friends of the Health Resources and Services
                                 Administration
        The Friends of the Health Resources and Services Administration
    (HRSA) is a nonprofit and nonpartisan alliance of more than 140
    national organizations, collectively representing millions of public
    health and healthcare professionals, academicians, and consumers. The
    coalition's principal goal is to ensure that HRSA's broad health
    programs have continued support in order to reach the populations
    presently underserved by the Nation's patchwork of health services.
        Through its programs in every State and thousands of communities
    across the country, HRSA is a national leader in providing a health
    safety net for medically underserved individuals and families,
    including 86.7 million Americans who were uninsured for some or all of
    2007-2008; 50 million Americans who live in neighborhoods where primary
    health services are scarce; more than 1 million people living with HIV/
    AIDS, and 34 million vulnerable mothers and children, including
    children with special health needs. In the best professional judgment
    of the members of the Friends of HRSA, to respond to this challenge,
    the agency will require an overall funding level of at least $8.5
    billion for fiscal year 2010.
        For several years, HRSA has suffered from relatively level funding,
    undermining the ability of its successful programs to grow. Our request
    reflects the minimum amount necessary for HRSA to adequately meet the
    needs of the populations they serve in fiscal year 2010, especially
    during these difficult economic times that are causing an increase in
    demand for HRSA programs and funding. Much more is needed for the
    agency to achieve its ultimate mission of ensuring access to culturally
    competent, quality health services for all; eliminating health
    disparities; and rebuilding the public health and healthcare
    infrastructure.
        The coalition is very appreciative of the $2.5 billion HRSA
    received in the American Recovery and Reinvestment Act of 2009 for
    community health centers and health professions workforce development
    to prepare our health infrastructure for health system reform. This
    investment recognizes the critical role HRSA plays in building the
    foundation for health service delivery. However, we urge the
    subcommittee to support adequately funding all of HRSA's broad health
    programs and ensure that vulnerable populations transition smoothly
    into a new health system and receive continued, quality health
    services. By supporting, planning for and adapting to change, we can
    build on the successes of the past and address the new gaps that emerge
    as a result of health system reform.
        Our $8.5 billion funding request is based on recommendations
    provided by coalition members for the various programs they focus on.
    It includes $2.602 billion for the Health Centers program, the fully
    authorized level under the Health Care Safety Net Act of 2008, as part
    of a long-term plan to provide care to 30 million Americans by 2015.
    Thanks to the leadership of the subcommittee, more than 7,000 health
    centers in every State and territory provide a healthcare home for more
    than 18 million medially underserved and low-income patients, and
    demand for their services continues to grow. The Health Centers program
    targets populations with special needs, including migrant and seasonal
    farm workers, homeless individuals and families, and those living in
    public housing. Health centers provide access to high-quality, family-
    oriented, culturally and linguistically competent primary care and
    preventive services, including mental and behavioral health, vision,
    and dental services. While recent growth in the health centers program
    has been substantial, a significant need remains in underserved
    communities across the country. We strongly encourage the subcommittee
    to continue its support of existing health centers and efforts to
    expand the reach and scope of the Health Centers program into new
    communities.
        Coalition members recommend $235 million for the National Health
    Service Corps (NHSC), the amount authorized under the Health Care
    Safety Net Amendments of 2002. Approximately 50 million Americans live
    in communities with a shortage of health professionals, lacking
    adequate access to primary care. The Corps supports the recruitment and
    retention of primary care clinicians to practice in underserved
    communities in exchange for scholarships and loan repayment. The Corps
    supports more than 4,000 clinicians, with over half working in
    community health centers. Growth in the Health Centers program must be
    complemented with growth in the recruitment and retention of primary
    care clinicians to ensure adequate staffing.
        Coalition members recommend $550 million for health professions
    programs under title VII and VIII of the Public Health Service Act.
    These programs are an essential component of America's health safety
    net and work in concert with the Health Centers Program and National
    Health Service Corps to enhance the supply, distribution and diversity
    of the health professions workforce. They are the only Federal programs
    that support the education and training of primary care providers in
    interdisciplinary settings to work in underserved communities and
    increase minority representation in the health professions workforce.
    Through loans, scholarships, and grants to academic institutions and
    nonprofit organizations, these programs provide support for the
    training of primary care physicians, nurses, dentists, optometrists,
    physician assistants, nurse practitioners, public health personnel,
    mental and behavioral health professionals, pharmacists, health
    educators, and other allied health providers. Adequate funding will
    reduce provider shortages in rural, medically underserved and federally
    designated health professions shortage areas and strengthen the
    pipeline of new providers that Health Centers and other safety-net
    health facilities need to meet the long-term needs of underserved
    communities. In addition, we recommend funds be appropriated to re-
    establish the National Center for Health Workforce Analysis to conduct
    and support statistical and epidemiological activities for assessing
    and improving decisionmaking to enhance the supply, distribution,
    diversity, and development of the current and future public health
    workforce. Finally, we urge the subcommittee to provide funding for the
    grant program under section 758 of the Public Health Service Act to
    develop interdisciplinary training and education programs on domestic
    violence and other types of violence and abuse as authorized by the
    Violence Against Women and Department of Justice Reauthorization Act of
    2005.
        We recommend $330 million for the Children's Hospital Graduate
    Medical Education (GME) Program, the amount authorized under the
    Children's Hospital GME Support Reauthorization Act of 2006. This
    program provides funds to freestanding children's hospitals to support
    the training of pediatric and other residents in GME programs. This
    program ensures that pediatric hospitals receive Federal funding
    comparable to other types of hospitals. We also request a significant
    investment in the Patient Navigator program that places navigators in
    underserved communities to help people with cancer and/or other chronic
    diseases make their way through the health systems and utilize
    community services that will help them beat chronic disease for longer,
    healthier lives.
        We recommend $850 million for the Maternal and Child Health (MCH)
    block grant, the fully authorized level under title V of the Social
    Security Act. For more than 70 years, the MCH block grant has provided
    a source of flexible funding for States and territories to address
    their unique needs related to improving the health of mothers, infants,
    children, adolescent, and children with special healthcare needs.
    Today, this program provides prenatal services to more than 2 million
    mothers--almost half of all mothers who give birth annually--and
    primary and preventive care to more than 17 million children, including
    almost 1 million children with special needs. Fully funding the MCH
    block grant will enable States to expand critical health services and
    cope with ever increasing medical costs.
        Newborn screening is a vital public health activity used to
    identify and treat genetic, metabolic, hormonal, and functional
    conditions in newborns. Screening detects heritable disorders in
    newborns that, if left untreated, can cause disability, mental
    retardation, serious illnesses, or even death. While nearly all babies
    born in the United States undergo newborn screening for genetic birth
    defects, the number of these tests varies from State to State. We
    recommend $30 million for the Heritable Disorders Program to support
    State efforts to improve programs, to acquire innovative testing
    technologies, and to increase capacity to reach and educate health
    professionals and parents on newborn screening programs and follow-up
    services. These activities and the funding level are authorized by the
    Newborn Screening Saves Lives Act.
        We recommend $16 million for the Traumatic Brain Injury (TBI)
    program in order to better serve the 5.3 million Americans with a long-
    term or lifelong need for help to perform daily activities as a result
    of a TBI, including many of our returning war veterans. The TBI Program
    provides grants to States to coordinate, expand, and enhance service
    delivery systems in order to improve access to services and support for
    persons with TBI and their families. The TBI program also provides
    funds to State protection and advocacy programs that work to ensure
    that people with TBI get access to the supports and services they need.
        We recommend $25 million for the Emergency Medical Services for
    Children (EMSC) program to address significant shortcomings in
    pediatric emergency care. The EMSC program is a national initiative
    designed to reduce child and youth disability and death due to severe
    illness and injury. EMSC grants provide funding for States and
    territories to improve existing emergency medical services systems and
    develop better procedures and protocols for treating children.
    Additional funding is needed to maintain and improve the program's
    activities, take advantage of important opportunities and address
    emerging threats such as terrorism.
        We recommend $2.816 billion for the Ryan White HIV/AIDS programs,
    which is the estimated amount necessary to provide health services to
    all eligible individuals. The Ryan White programs provide the largest
    source of Federal discretionary funding to support health services for
    more than 500,000 low-income, uninsured, and underinsured people living
    with HIV/AIDS. Through grants to State and local governments and
    community-based organizations, the Ryan White HIV/AIDS programs support
    comprehensive care, drug assistance and support services for people
    living with HIV/AIDS; provide training for health professionals
    treating people with HIV/AIDS; provide assistance to metropolitan and
    other areas most severely affected by the HIV/AIDS epidemic; and
    address the disproportionate impact of HIV/AIDS on women and
    minorities. A significant funding increase is needed to meet growing
    medical costs and incidence of HIV, particularly among underserved
    populations.
        The Office of Rural Health Policy promotes better health services
    for the 60 million Americans who live in rural communities. These
    communities suffer from inadequate access to quality health services
    and experience the higher rates of illness associated with lower
    socioeconomic status. Rural Health Outreach and Network Development
    Grants, and other programs are designed to support community-based
    disease prevention and health promotion projects, help rural hospitals
    and clinics implement new technologies and strategies, and build health
    system capacity in rural and frontier areas. In addition, Rural Health
    Research Centers help policymakers better understand the challenges
    that rural communities face in assuring access to health services and
    improving the health of their residents. Finally, the Rural and
    Community Access to Emergency Devices Program provides States with
    grants to train lay rescuers and first responders to use automated
    external defibrillators (AEDs) and purchase and place them in public
    areas where sudden cardiac arrests are likely to occur. We encourage
    the subcommittee to adequately fund these important programs that
    address the many unique health service needs of rural communities.
        We recommend $700 million for the Family Planning programs under
    title X of the Public Health Service Act. Title X programs provide
    comprehensive, voluntary, and affordable family planning services to
    nearly 5 million low-income women at more than 4,500 clinics
    nationwide. Title X funded clinics help improve access to
    contraceptives, which help women plan the number and timing of their
    pregnancies, improve maternal and infant health, and help to prevent
    approximately 1.94 million unintended pregnancies each year, including
    nearly 400,000 teenage pregnancies. The Guttmacher Institute estimates
    that unintended pregnancies prevented each year would have resulted in
    810,000 abortions and without publicly funded family planning programs,
    the U.S. abortion rate would be nearly two-thirds higher than the
    current level. Family planning is also cost-saving and for every public
    dollar invested in family planning, $3.80 is saved in costs associated
    with unintended births to women who are eligible for Medicaid. Today,
    almost 17 million women need publicly supported contraceptive care--a
    number which continues to grow. Title X programs require a substantial
    increase in investment to meet the growing demand.
        The Healthcare Systems Bureau provides national leadership on the
    transplantation of organs, bone marrow and cord blood. The recently
    passed Budget Resolution Conference Agreement calls for increased
    funding for ``the organ transplant program.'' Coalition members
    recommend $35 million for the Division of Transplantation in order to
    meet the Office of Management and Budget's goal of doubling the number
    of transplants by 2013 and reduce the waiting list of 101,951 people in
    need of a life saving organ transplant. We recommend $38 million for
    the C.W. Bill Young Cell Transplantation Program, the amount authorized
    by the Stem Cell Therapeutic and Research Act of 2005. This program
    helps patients who need a potentially life-saving bone marrow or cord
    blood transplant, including patients with diseases like leukemia,
    lymphoma, sickle cell anemia, or other inherited metabolic or immune
    system disorders. We also recommend the fully authorized $15 million
    for the National Cord Blood Inventory, which collects and maintains
    high-quality cord blood units and makes them available for
    transplantation through the C.W. Bill Young Cell Transplantation
    Program.
        Poison Control Centers, also administered by the Healthcare Systems
    Bureau, are a critical resource for people, health professionals, and
    organizations. Poisoning can happen to anyone, at anytime in any place
    and can lead to serious illness or even death. Each year, more than 2
    million possible poisonings are reported to the nation's poison
    centers. On average, poison centers handle one possible poisoning every
    13 seconds. These critical centers cannot afford to lose any resources
    and we encourage the subcommittee to fully fund this program.
        Finally, we recommend a significant funding increase for HRSA's
    program management and staffing needs. Since 2001, HRSA has experienced
    a decline of almost 600 full-time equivalent employees. While HRSA has
    continued to administer its many programs effectively, the agency if
    facing ever growing demands as a result of the economic crisis and a
    changing health system. We strongly urge the subcommittee to increase
    program management funds to provide the agency with the necessary human
    and other resources to ensure the programs it administers are effective
    and improve the health of the American public.
        We appreciate the subcommittee's hard work in advocating for HRSA's
    programs in a climate of competing priorities. The members of the
    Friends of HRSA thank you for considering our fiscal year 2010 request
    for $8.5 billion for HRSA and are grateful for this opportunity to
    present our views to the subcommittee.
        We the undersigned organizations, thank you for your attention to
    this matter.
                        Academic Pediatric Association; Advocates for
                                Youth; AIDS Action; AIDS Alliance for
                                Children, Youth and Families; AIDS
                                Foundation of Chicago; AIDS Project Los
                                Angeles; The Alan Guttmacher Institute;
                                Allergy and Asthma Network Mothers of
                                Asthmatics; Alliance for Academic Internal
                                Medicine; American Academy of Family
                                Physicians.
                        American Academy of Nurse Practitioners; American
                                Academy of Nursing; American Academy of
                                Ophthalmology; American Academy of
                                Pediatrics; American Academy of Physician
                                Assistants; American Association of
                                Colleges of Podiatric Medicine; American
                                Association for Dental Research; American
                                Association of Colleges of Nursing;
                                American Association of Colleges of
                                Osteopathic Medicine; American Association
                                of Colleges of Pharmacy; American
                                Association of Family and Consumer
                                Services.
                        American Association of Nurse Anesthetists;
                                American Association of Orthopedic
                                Surgeons; American Association on
                                Intellectual and Developmental
                                Disabilities; American Cancer Society;
                                American College of Nurse-Midwives;
                                American College of Obstetricians and
                                Gynecologists; American College of
                                Physicians; American College of
                                Preventative Medicine; American Counseling
                                Association; American Dental Association.
                        American Dental Education Association; American
                                Dental Hygienists' Association; American
                                Dietetic Association; American Federation
                                of State, County and Municipal Employees;
                                American Foundation for AIDS Research;
                                American Heart Association; American
                                Hospital Association; American Medical
                                Student Association; American Medical
                                Women's Association; American Nephrology
                                Nurses' Association.
                        American Nurses Association; American Occupational
                                Therapy Association; American Optometric
                                Association; American Pediatric Society;
                                American Physical Therapy Association;
                                American Podiatric Medicine Association;
                                American Psychiatric Association; American
                                Psychological Association; American Public
                                Health Association; American Red Cross.
                        American School Health Association; American
                                Society for Microbiology; American Society
                                for Reproductive Medicine; Americans for
                                Democratic Action; The Arc; Asian and
                                Pacific Islander American Health Forum;
                                Association for Prevention Teaching and
                                Research; Association of Academic Health
                                Centers; Association of American Medical
                                Colleges; Association of American
                                Veterinary Medical Colleges.
                        Association of Clinicians for the Underserved;
                                Association of Departments of Family
                                Medicine; Association of Family Medicine
                                Residency Directors; Association of
                                Maternal and Child Health Programs;
                                Association of Medical School Pediatric
                                Department Chairs; Association of Minority
                                Health Professions Schools; Association of
                                Organ Procurement Organizations;
                                Association of Professors of Medicine;
                                Association of Public Health Laboratories;
                                Association of Reproductive Health
                                Professionals.
                        Association of Schools of Allied Health
                                Professionals; Association of Schools of
                                Public Health; Association of State and
                                Territorial Directors of Nursing;
                                Association of State and Territorial Health
                                Officials; Association of University
                                Centers on Disabilities; Association of
                                Women's Health, Obstetric and Neonatal
                                Nurses; Avancer Health Policy; CAEAR
                                Coalition; Catholic Health Association of
                                the U.S.; Center for Health Policy Research
                                and Ethics, GMU.
                        Center for the Advancement of Health; Center for
                                Women Policy Studies; Center on Disability
                                and Health; Charles Drew University;
                                Children's Defense Fund; Coalition for
                                American Trauma Care; Coalition for Health
                                Funding; Coalition for Health Services
                                Research; Consortium of Social Science
                                Associations; Council of Accredited MPH
                                Programs.
                        Easter Seals; Emergency Nurses Association;
                                Epilepsy Foundation; Families USA; Family
                                Violence Prevention Fund; Health and
                                Medicine Counsel of Washington; HIV
                                Medicine Association; Human Rights
                                Campaign; Infectious Diseases Society of
                                America; Institute for Children's
                                Environmental Health.
                        Latino Council on Alcohol and Tobacco; Legal Action
                                Center; March of Dimes; Meharry Medical
                                College; Morehouse School of Medicine;
                                NAADAC, the Association for Addiction
                                Professionals; National AHEC Organization;
                                National Alliance of State and Territorial
                                AIDS Directors; National Assembly on
                                School-Based Health Care; National
                                Association of Addiction Treatment
                                Providers; National Association of
                                Community Health Centers.
                        National Association of Councils on Developmental
                                Disabilities; National Association of
                                County and City Health Officials; National
                                Association of Local Boards of Health;
                                National Association of People with AIDS;
                                National Association of Public Health
                                Statistics and Information Systems;
                                National Association of Public Hospitals
                                and Health Systems; National Association of
                                Rural Health Clinics; National Association
                                of Social Workers; National Associations of
                                Children's Hospitals; National Black Nurses
                                Association.
                        National Coalition for the Homeless; National
                                Council for Diversity in the Health
                                Professions; National Council of La Raza;
                                National Disability Rights Network;
                                National Episcopal AIDS Coalition; National
                                Family Planning and Reproductive Health
                                Association; National Health Care for the
                                Homeless Council; National Hemophilia
                                Foundation; National Hispanic Medical
                                Association; National League for Nursing.
                        National Marrow Donor Program; National Medical
                                Association; National Minority AIDS
                                Council; National Network for Youth;
                                National Rural Health Association; North
                                American Primary Care Research Group;
                                Oncology Nursing Society; Organizations of
                                Academic Family Medicine; Partnership for
                                Prevention; Planned Parenthood Federation
                                of America.
                        Sexuality Information and Education Council of the
                                United States; Society for Adolescent
                                Medicine; Society for Pediatric Research;
                                Society for Public Health Education;
                                Society for the Psychological Study of
                                Social Issues; Society of General Internal
                                Medicine; Society of Teachers of Family
                                Medicine; The AIDS Institute; Trust for
                                America's Health; U.S. Conference of
                                Mayors.
                                     ______

           Letter From The Friends of the National Institute on Aging
        Dear Chairman Harkin and members of the subcommittee: I am writing
    to request the opportunity to testify at the fiscal year 2010 public
    witness hearing on behalf of The Friends of the National Institute on
    Aging regarding the important role that the National Institute on Aging
    (NIA) plays among the National Institutes of Health and the need for
    increased appropriations to ensure sustained, long-term growth in aging
    research in the fiscal year 2010 budget and beyond.
        The Friends of the NIA is a coalition of 50 academic, patient-
    centered and not-for-profit organizations that conduct, fund, or
    advocate for scientific endeavors to improve the health and quality of
    life for Americans as we age. We support the continuation and expansion
    of NIA research activities and seek to raise awareness about important
    scientific progress in the area of aging research currently guided by
    the Institute. I serve as Chair of the Friends of the NIA and as such,
    am respectfully requesting permission to testify on behalf of the
    Friends of the NIA before the subcommittee.
        Our testimony highlights the relevance of the work of the NIA to
    each and every American, as well as opportunities for future progress
    that are dependent on Congressional action to build upon the
    unprecedented $10.4 billion in the American Recovery and Reinvestment
    Act for NIH research and training activities in fiscal year 2010. I
    have attached a copy of our testimony for your review.
        Mr. Chairman, The Friends of the NIA thanks you in advance for this
    opportunity to outline the challenges and opportunities that lie ahead
    as you consider the fiscal year 2010 appropriations for the NIH.
                Regards,
                                         Kimberly D. Acquaviva,
                                                                 Chair.
                                     ______

                  Prepared Statement of the FSH Society, Inc.
        Mr. Chairman, it is a great pleasure to submit this testimony to
    you today.
        My name is Daniel Paul Perez, of Bedford, Massachusetts, and I am
    testifying today as President and CEO of the FSH Society, Inc.
    (facioscapulohumeral muscular dystrophy) and as an individual who has
    this common and most prevalent form of muscular dystrophy.
        the need for national institute of health (nih) funding for fshd
        My testimony is about the profound and devastating effects of a
    disease known as facioscapulohumeral muscular dystrophy which is also
    known as facioscapulohumeral muscular disease, FSH muscular dystrophy
    or FSHD, and the urgent need for increased NIH funding for research on
    this disorder.
        According to our research, only a limited amount of work is going
    on across all the Institutes at the NIH. In fact, only 3 of the 27
    Institutes at the NIH are funding FSHD research, e.g., the National
    Institute of Neurological Disorders and Stroke (NINDS), the National
    Institute of Arthritis, Musculoskeletal and Skin Disease (NIAMS), and
    the Eunice Kennedy Shriver National Institute of Child Health and Human
    Development (NICHD). Currently, the level of funding from NINDS, NICHD,
    and NIAMS for FSHD research is approximately $3,093,269.
        Since 1994, I have submitted testimony before both House and Senate
    Appropriations Committees' Subcommittee on Labor, Health and Human
    Services, and Education and Related Agencies which stated that NIH and
    Congress with modest investments could help bring about a significant
    research and scientific opportunity which would benefit hundreds of
    thousands of people worldwide.
        Today, I am asking Congress to communicate to the Public Health
    Service and National Institutes of Health the need for research funding
    on the FSHD disorder at a level of $10,000,000 annually in fiscal year
    2010.
                                living with fshd
        As a man with facioscapulohumeral muscular dystrophy, I will tell
    you that it is a hard way to live, and that FSHD is a strong fort--it
    will last a lifetime. Unless Congress mandates that the NIH ensure that
    it receives sufficient grant applications of highest quality on FSHD
    and to spend an equitable ratio of NIH muscular dystrophy dollars on
    FSHD, which is now conservatively $10 million.
        At 47 years of age, I consider myself a lifelong survivor of the
    severe trauma and tension of FSHD, and I do not say this lightly. I
    have dealt with the continuing, unrelenting, and unending loss caused
    by FSHD from the first second, into the first minute, hour, day, week,
    over the months and through the years. Not for a moment is there a
    reprieve from continual loss of my physical ability; not for a moment
    is there a time for me to mourn; not for a moment is there relief from
    the physical and mental pain that is a result of this disease. There is
    no known treatment and no known cause for this disease.
        Look at what this disease does to people. Look at me. Look at what
    I see--a child with a profound hearing loss, the broken innocence of a
    child, alienation at an early age, a decision not to marry, a decision
    not to have biological children, disability in the prime of life,
    incapacitation in middle age, the guilt of a parent, a lifetime of
    physical challenge, a suicide, a premature death, anxiety caused by
    uncontrollable loss, decades spent somewhere between the able and the
    disabled, the loss of ambulating, the unstoppable atrophy and loss of
    muscle and the humiliation endured in the process.
        For men, women, and children the major consequence of inheriting
    the most prevalent form of muscular dystrophy, FSHD, is a lifelong
    progressive and severe loss of all skeletal muscles. FSHD is a
    terrible, crippling and life shortening disease. No one is immune, it
    is genetically and spontaneously (by mutation) transmitted to children
    and it affects entire family constellations.
         the most prevalent form of muscular dystrophy is now markedly
                               underfunded at nih
        It is a fact that FSHD is now published in the scientific
    literature as the most prevalent muscular dystrophy in the world. The
    incidence of the disease is conservatively estimated to be 1 in 14,285.
    The prevalence of the disease, those living with the disease ranges to
    two or three times as many as that number based on our increasing
    experiences with the disease and more available and accurate genetic
    diagnostic tests.
        The French Government research agency INSERM (Insitut National de
    la Sante et de la Recherche Medicale) is comparable to the NIH, and it
    recently published prevalence data for hundreds of diseases in Europe.
    Notable is the ``Orphanet Series'' reports covering topics relevant to
    all rare diseases. The ``Prevalence or reported number of published
    cases listed in alphabetical order of disease''. This update contains
    new epidemiological data and modifications to existing data for which
    new information has been made available. This new information ranks
    facioscapulohumeral muscular dystrophy (FSHD) as the most prevalent
    muscular dystrophy followed by Duchenne (DMD) and Becker Muscular
    dystrophy (BMD) and then, in turn, myotonic dystrophy (DM). FSHD is
    historically presented as the third-most prevalent muscular dystrophy
    in the Muscular Dystrophy Community Assistance, Research and Education
    Amendments of 2001 and 2008 (the MD-CARE Act). This new data ranks FSHD
    as the first and most prevalent.

    ------------------------------------------------------------------------
                      Estimated prevalence                     Cases/100,000
    ------------------------------------------------------------------------
    Facioscapulohumeral muscular dystrophy (FSHD)...........       7/100,000
    Duchenne (DMD) and Becker Muscular dystrophy (BMD) types       5/100,000
    Steinert myotonic dystrophy (DM)........................     4.5/100,000
    ------------------------------------------------------------------------

     nih muscular dystrophy funding has tripled since the inception of the
                    md care act ($21 million to $56 million)
        Between fiscal year 2006 and 2007, NIH overall funding for muscular
    dystrophy increased from $39,913,000 to $47,179,000, an 18 percent
    increase.
        Between fiscal year 2007 and 2008, NIH overall funding for muscular
    dystrophy decreased as shown in the ``Estimates of Funding for Various
    Research, Condition, and Disease Categories (RCDC)'' report on the new
    Research Portfolio Online Reporting Tool (RePORT) from $58 million to
    $56 million, a 3 percent decrease. These figures are from the new
    ``2007/2008 NIH Revised Method'' columns. The same RCDC RePORT system
    report shows $47 million as the 2007 figure under the ``2007 NIH
    Historical Method'' column, a 23 percent increase and restatement when
    converting to the new system.
        Figures from the RCDC RePORT and the NIH Appropriations History for
    Muscular Dystrophy report historically provided by NIH/Office of the
    Director (OD) Budget Office and NIH OCPL show that from the inception
    of the MD CARE Act 2001, funding has nearly tripled from $21 million to
    $56 million for muscular dystrophy.
    nih fshd funding has remained level since the inception of the md care
                          act ($3 million/$56 million)
        Between fiscal year 2006 and 2007, NIH funding for FSHD increased
    from $1,732,655 to $4,108,555. In fiscal 2007, FSHD was 8.7 percent of
    the total muscular dystrophy funding ($4.109 million/$47.179 million).
        Between fiscal year 2007 and 2008, NIH funding for FSHD decreased
    from $4,108,555 to $3 million under the ``2007 and 2008 NIH Revised
    Method.'' The ``2007 NIH Historical Method'' was restated to $3
    million. In fiscal 2008 under ``NIH Revised Method,'' FSHD was 5.3
    percent of the total muscular dystrophy funding ($3 million /$56
    million). The previous years 2006/2007 figures are revised and restated
    under ``2007 NIH Historical Method'' as ($3 million/$58 million) which
    is 5.1 percent of the total muscular dystrophy funding. FSHD funding
    has merely kept its ratio in the NIH funding portfolio and has not
    grown in the last 7 years.
        We highly commend the Director of the NIH on the ease of use and
    the accuracy of the Research Portfolio Online Reporting Tool (RePORT)
    report ``Estimates of Funding for Various Research, Condition, and
    Disease Categories (RCDC)'' with respect to reporting projects on
    facioscapulohumeral muscular dystrophy.

           NATIONAL INSTITUTES OF HEALTH (NIH) APPROPRIATIONS HISTORY
                              [Dollars in millions]
    ------------------------------------------------------------------------
                                                                   FSHD
                                               FSHD research   percentage of
                   Fiscal year                    dollars        muscular
                                                                 dystrophy
    ------------------------------------------------------------------------
    2002....................................            $1.3               5
    2003....................................             1.5               4
    2004....................................             2.2               6
    2005....................................               2               5
    2006....................................             1.7               4
    2007....................................               3               5
    2008....................................               3               5
    ------------------------------------------------------------------------

        The MD CARE Act 2008 mandates the NIH Director to intensify efforts
    and research in the muscular dystrophies, including FSHD, across the
    entire NIH. It should be very concerning that in the last 7 years
    muscular dystrophy has tripled to $56 million and that FSHD has
    remained at 5 percent of the NIH muscular dystrophy portfolio or $3
    million. Only three of the Institutes at the NIH are funding FSHD. OD,
    National Heart, Lung, and Blood Institute, National Institute of
    General Medical Sciences, National Institute of Biomedical Imaging and
    Bioengineering, National Institute on Deafness and Other Communication
    Disorders, National Human Genome Research Institute , NEI, National
    Institute on Aging, National Cancer Institute, and National Center for
    Research Resources are all aware of the high impact each could have on
    FSHD. FSHD is certainly still far behind when we look at the breadth of
    research coverage NIH-wide.
        Now, FSHD is published as the most prevalent muscular dystrophy,
    and given the extraordinary interest of the scientific and clinical
    communities in its unique disease mechanism, it defies gravity that it
    still remains the most prevalent and one of the most underfunded
    dystrophies at the NIH and in the Federal research agency system
    (Centers for Disease Control and Prevention, Department of Defense, and
    Food and Drug Administration). In 2008, the third most prevalent
    dystrophy, Duchenne (DMD) and Becker Muscular dystrophy (BMD) type,
    received $22 million from NIH. In 2008, the second most prevalent
    dystrophy myotonic dystrophy (DM), received $9 million from NIH. In
    2008, the most prevalent dystrophy, FSHD, received $3 million from NIH.
    It is now time to flip the stack and to make sure that FSHD with its
    equal burden of disease and highest prevalence gets more funding,
    stimulus and that NIH program staff initiates request for applications
    specifically in FSHD. It is crystal clear, if not completely black and
    white, that the open mechanism program announcement and investigator
    driven model are not achieving the goal mandated by the MD CARE Acts
    2001/2008 and by the NIH Action Plan for the Muscular Dystrophies as
    submitted to the Congress by the NIH. Efforts of excellent program
    staff and leadership at NIH, excellent reviewers and study sections,
    excellent and outstanding researchers working on FSHD and submitting
    applications to the NIH, and extraordinary efforts of the volunteer
    health agencies working in this area have not yet enabled FSHD funding
    to increase at the NIH. It is time for NIH requests, contracts, and
    calls for researcher proposals on FSHD to bootstrap existing FSHD
    research worldwide.
        I am here once again to remind you that FSHD is taking its toll on
    your citizens. FSHD illustrates the disparity in funding across the
    muscular dystrophies and recalcitrance in growth over 20 years despite
    consistent pressure from appropriations language and Appropriations
    Committee questions, and an authorization and a reauthorization from
    Congress mandating research on FSHD.
               our request to the nih appropriations subcommittee
        We request this year in fiscal year 2010, immediate help for those
    of us coping with and dying from FSHD. We ask NIH to fund research on
    FSHD at a level of $10 million in fiscal year 2010.
        We implore the Appropriations Committee to request that the
    Director of NIH, the chairman/chairwoman, and executive secretary of
    the Federal advisory committee Muscular Dystrophy Coordinating
    Committee mandated by the MD CARE Act of 2008, to increase the amount
    of FSHD research and projects in its portfolios using all available
    passive and pro-active mechanisms and interagency committees. Given the
    knowledge base and current opportunity for breakthroughs in treating
    FSHD it is inequitable that only 3 of the 12 NIH Institutes covering
    muscular dystrophy have a handful of research grants for FSHD. We
    request that the Director of the NIH be more proactive in facilitating
    grant applications (unsolicited and solicited) from new and existing
    investigators and through new and existing mechanisms, special
    initiatives, training grants and workshops--to bring knowledge of FSHD
    to the next level.
        Thanks to your efforts and the efforts of your subcommittee, Mr.
    Chairman, the Congress, the NIH and the FSH Society are all working to
    promote progress in FSHD. Our successes are continuing and your support
    must continue and increase.
        We ask you to fund NIH research on FSHD at a level of $10 million
    in fiscal year 2010.
        Mr. Chairman, thank you for this opportunity to testify before your
    subcommittee.
                                     ______

           Prepared Statement of the Family Violence Prevention Fund
        The Family Violence Prevention Fund (FVPF) works to end violence
    against women and children around the world, because every person has
    the right to live free of violence. The FVPF's National Health Resource
    Center on Domestic Violence provides critical information to thousands
    of healthcare providers, institutions, domestic violence service
    providers, Government agencies, researchers, and policy makers each
    year. Its public education campaigns, conducted in partnership with The
    Advertising Council, have shaped public awareness and changed social
    norms for 15 years.
     strengthening the healthcare system's response to domestic violence,
                 dating violence, sexual assault, and stalking
        Through our work as the National Health Resource Center on Domestic
    Violence, I know the critical role healthcare providers can play in
    preventing and responding to violence against women and children,
    particularly during this difficult economic time when rates of abuse in
    families seem to be rising. But it is not simply a moral imperative
    that we try to reduce violence and abuse in this country; it is an
    economic necessity that Congress supports prevention and intervention
    efforts in the healthcare system. The Centers for Disease Control and
    Prevention (CDC) classifies violence and abuse as a ``substantial
    public health problem in the United States,'' noting the long-term
    impact of violence and abuse has huge implications for health outcomes
    and costs.
        Children who experience childhood trauma, including witnessing
    incidents of domestic violence, are at a greater risk of having serious
    adult health problems including tobacco use, substance abuse, cancer,
    heart disease, depression and a higher risk for unintended pregnancy.
    Twenty years of research links childhood exposure to violence with
    chronic health conditions including obesity, asthma, arthritis, and
    stroke. It is worth noting that victims, particularly of sexual
    violence, are linked with obesity. A meta-analysis of research on the
    impact of adult intimate partner violence finds that victims of
    domestic violence are at increased risk for conditions such as heart
    disease, stroke, hypertension, cervical cancer, chronic pain including
    arthritis, neck and pain, and asthma. In addition to injuries, adult
    intimate partner violence also contributes to a number of mental health
    problems including depression and PTSD, risky health behaviors such as
    smoking, alcohol and substance abuse, and poor reproductive health
    outcomes such as unintended pregnancy, pregnancy complications,
    postpartum depression, poor infant health outcomes and sexually
    transmitted infections including HIV.
        According to a CDC survey, women who have experienced domestic
    violence are 80 percent more likely to have a stroke, 70 percent more
    likely to have heart disease, 60 percent more likely to have asthma and
    70 percent more likely to drink heavily than women who have not
    experienced intimate partner violence.
        When Congress joined together to reauthorize the Violence Against
    Women Act (VAWA) of 2005 (Public Law 109-162), the law included new
    provisions to educate and train healthcare providers and public health
    professionals on how to safely screen and intervene in cases of
    domestic and sexual violence. These provisions were added after years
    of work by medical associations, health professionals, advocates and a
    National Health Care Standards Campaign on Domestic Violence funded by
    the U.S. Department of Health and Human Services. These collaborations
    successfully developed strategies, tools, and policies to identify and
    help victims in health settings.
        We know that most women seek healthcare services regularly, either
    for routine, emergency, perinatal, or pediatric care. As a result,
    healthcare providers are in a unique position to identify and reach out
    to victims of violence, long before they may seek help from a domestic
    violence shelter, rape crisis center, law enforcement agency, or family
    member. However, fewer than 10 percent of primary care physicians
    routinely screen patients for domestic violence during regular office
    visits, according to a study published by the Journal of the American
    Medical Association.
        Research on the most effective interventions in the healthcare
    setting and prevention messages would have significant public health
    benefits and cost savings to the healthcare system. While we do not
    know the full cost of violence and abuse to the healthcare system,
    previous studies have shown that those who experience abuse access
    healthcare 2 to 2.5 times more frequently than those without that
    history. Research shows that intimate partner violence alone costs a
    health plan $19.3 million each year for every 100,000 women between the
    ages of 18 and 64 enrolled.
        Far more important is the cost of violence and abuse over time.
    Even 5 years after abuse has ended, healthcare costs for women with a
    history of intimate partner violence remain 20 percent higher than
    those for women with no history of violence. A study by the CDC in 2003
    estimated the direct medical costs of only injuries and mental health
    services related to intimate partner violence at $4.1 billion alone,
    this does not include any evaluation of costs associated with chronic
    health issues or reproductive health issues discussed above and known
    to be highly prevalent among victims of abuse. A recent report by the
    Academy on Violence and Abuse estimated the actual cost to the
    healthcare system of violence and abuse may be nearly 17 percent of the
    total healthcare dollar or $333 billion in 2008.
        But early identification and treatment of victims can financially
    benefit the healthcare system. Initial and unpublished findings from
    one study found that hospital-based domestic violence interventions may
    reduce healthcare costs by at least 20 percent. Preventing abuse or
    associated health risks and behaviors clearly could have long term
    implications for decreasing chronic disease and costs. Because of the
    long-term impact of abuse on a patient's health, I recommend
    integrating assessment for current and lifetime physical or sexual
    violence exposure and interventions into routine care. Regular, face-
    to-face screening of women by skilled healthcare providers markedly
    increases the identification of victims of intimate partner violence
    (IPV), as well as those who are at risk for verbal, physical, and
    sexual abuse. Routine inquiry of all patients, as opposed to indicator-
    based assessment, increases opportunities for both identification and
    effective interventions, validates IPV as a central and legitimate
    healthcare issue, and enables providers to assist both victims and
    their children.
        When victims or children exposed to IPV are identified early,
    providers may be able to break the isolation and coordinate with
    domestic violence (DV) advocates to help patients understand their
    options, live more safely within the relationship, or safely leave the
    relationship. Expert opinion suggests that such interventions in adult
    health settings may lead to reduced morbidity and mortality. Assessment
    for exposure to lifetime abuse has major implications for primary
    prevention and early intervention to end the cycle of violence.
        Just as the healthcare system has always played an important role
    in identifying and preventing other serious public health problems, I
    believe it can and must play a pivotal role in domestic and sexual
    violence prevention and intervention. It is clear that by funding these
    innovative and life-saving health provisions established by title V in
    VAWA 2005, we can help save the lives of victims of violence and
    greatly reduce healthcare expenses.
        In order to advance necessary and needed health goals, I urge you
    to provide $13 million to the Department of Health and Human Services
    to fully fund the Violence Against Women Act's Health Care Programs for
    fiscal year 2010, and specifically fund the following Labor, Health and
    Human Services, and Education, and Related Agencies programs
    accordingly:
      --Training and Education of Health Professionals Program.--$3 million
            to train healthcare providers and students in health
            professional schools how to identify and screen victims of
            domestic and sexual violence; ensure immediate safety; document
            their injuries; and refer them to appropriate services;
      --Fostering Public Health Responses.--$5 million to promote public
            health programs that integrate domestic and sexual violence
            assessment and intervention into basic care, as well as
            encourage collaborations between healthcare providers, public
            health programs, and domestic and sexual violence programs; and
      --Research on Effective Interventions.--$5 million to support
            research and evaluation on effective interventions in the
            healthcare setting to improve abused women's health and safety
            and prevent initial victimization.
                    protect nonabusive parents and children
        Another area of concern is the intersection of domestic violence
    and child abuse, which often occur in the same family. Approximately 45
    percent of female caregivers of children reported for child
    maltreatment have experienced intimate partner violence in their
    lifetime and 29 percent in the past year. In a study of families
    investigated for child maltreatment, 31 percent of female caregivers
    reported experiencing intimate partner violence in the past year;
    however child welfare workers only identified this abuse in 12 percent
    of the families.
        When child welfare agencies work alone in responding to child
    maltreatment, they may not understand the complexity of the domestic
    violence situation and ``pre-emptively'' remove the child without
    offering services to the adult victim. This can have a devastating
    result for both the child and the nonabusive caretaker. In addition,
    the opposite approach may also be taken. Frequently, the child
    protective system fails to take seriously the threat posed by an
    abusive husband or partner and fails to take any action to support the
    mother's efforts to keep her and her children safe and hold him
    accountable for his actions.
        By supporting agencies in cooperative efforts to provide services
    to victims--both children and their nonabusive caretakers--it is
    possible to keep families safe and united during the difficult process
    of ending abuse.
     the solution: improve cooperation between child welfare and domestic
                               violence advocates
        Building on what was commonly known as the ``Greenbook Project,'' a
    federally funded demonstration grant program, VAWA 2005 authorized a
    program to create grants for training and collaboration on the
    intersection between domestic violence and child maltreatment. The
    intent is to ensure that nonabusive family members receive the services
    they need to keep their families safe, and community services can deal
    with both problems simultaneously, allowing for a better use of our
    limited resources. As the two problems often occur together, dealing
    with one problem and not the other is at the peril of our children.
        I urge you to fully fund Training and Collaboration on the
    Intersection Between Domestic Violence and Child Maltreatment Program
    at $5 million to help serve families experiencing violence.
        In addition, I ask that you continue to support full funding for
    the Family Violence Prevention and Services Act, the Nation's only
    designated Federal funding source for domestic violence shelters and
    services. As leaders committed to both the prevention of intimate
    partner violence and to the health and safety of victims, I urge you to
    fund these critical programs.
                                     ______

               Prepared Statement of the HIV Medicine Association
        The HIV Medicine Association (HIVMA) of the Infectious Diseases
    Society of America (IDSA) represents more than 3,600 physicians,
    scientists, and other healthcare professionals who practice on the
    frontline of the HIV/AIDS pandemic. Our members provide medical care
    and treatment to people with HIV/AIDS throughout the United States,
    lead HIV prevention programs and conduct research to develop effective
    HIV prevention and treatment options. As medical providers and
    researchers dedicated to the field of HIV medicine, we work in
    communities across the country and around the globe. We appreciate the
    fiscal challenges that you currently face, but the state of the economy
    makes it imperative that our Nation has a strong healthcare safety net,
    effective programs for preventing infectious diseases like HIV and a
    vibrant scientific research agenda.
        The U.S. investment in HIV/AIDS programs has revolutionized HIV
    care globally making HIV treatment one of the most effective medical
    interventions available. A robust research agenda and rapid public
    health implementation of scientific findings have transformed the HIV
    epidemic reducing morbidity and mortality due to HIV disease by nearly
    80 percent in the United States. The Ryan White program has played a
    critical role in ensuring that many low-income people with HIV have
    access to lifesaving HIV treatment. However, the impact of our
    diminished investment in public health and research programs over the
    last several years has taken its toll in communities across the
    country. HIV clinics are cutting hours and services while new HIV cases
    are increasing by at least 15 percent.
        We face a critical juncture when we must either shore up our
    healthcare safety net, public health infrastructure, and research
    programs or risk serious regression in our fight against this deadly
    disease. The funding requests in our testimony largely reflect the
    consensus of the Federal AIDS Policy Partnership (FAPP) a coalition of
    HIV organizations from across the country, and are estimated to be the
    amounts necessary to sustain and strengthen our investment in combating
    HIV disease.
     center for disease control and prevention's (cdc) national center for
          hiv/aids, viral hepatitis, std, and tb prevention (nchhstp)
        HIVMA strongly supports an increase of $1.27 billion in funding for
    the CDC's NCHHSTP with an increase of $878 million for HIV prevention
    and surveillance, an increase of $31.7 million for viral hepatitis and
    $66.1 million for Tuberculosis prevention.
        Every 9\1/2\ minutes a new HIV infection happens in the United
    States with more than 60 percent of new cases occurring among African
    Americans and Hispanic/Latinos. While new HIV cases have increased, the
    CDC's HIV prevention budget has declined 19 percent compared to
    inflation since 2002. A failure to invest now in HIV prevention will be
    costly. The CDC estimates that the 56,300 new HIV infections each year
    in the United States may result in $56 billion in medical care and lost
    productivity.
        We strongly support the CDC initiative to integrate HIV screening
    into medical care and remain seriously concerned about the lack of
    Federal resources available to State health departments, medical
    institutions, community health centers, and other community-based
    organizations for implementing these programs. Increased HIV screening
    with linkage to care and treatments will help lower HIV incidence and
    prevalence in the United States. Effective treatment reduces the virus
    to very low levels in the body and greatly reduces the risk of HIV
    transmission. Furthermore through education, counseling and treatment,
    individuals who are aware that they have HIV are less likely to
    transmit the virus. The transmission rates among people who know their
    status is 1.7 percent to 2.4 percent compared to transmission rates of
    8.8 percent to 10.8 percent for those who are unaware they are infected
    with HIV.
        Despite the known benefit of effective treatment, 21 percent of
    people living with HIV in the United States are still not aware of
    their status and as many as 36 percent of people newly diagnosed with
    HIV progress to AIDS within 1 year of diagnosis. Identifying people
    with HIV earlier through routine HIV testing and linking them to HIV
    care saves lives and is more cost effective for the healthcare system.
    One study found that people living with HIV disease receiving care at
    the later stages of the disease expended 2.6 times more in healthcare
    dollars than those receiving treatment according to the standard of
    care recommended in the Federal HIV treatment guidelines.
        An infusion of HIV prevention funding is critical to restore and
    enhance HIV prevention cooperative agreements with State and local
    health departments; to optimize core surveillance cooperative
    agreements with health departments and to expand HIV testing in key
    healthcare venues by funding testing infrastructure, the purchase of
    approved testing devices, including rapid HIV tests and confirmatory
    testing.
        Finally, we also must increase support for science-based,
    comprehensive sex education programs. We strongly urge Congress to
    discontinue funding for unproven abstinence-only sex education programs
    and shift these funds to support comprehensive, age-appropriate sex
    education programs.
                               cdc--tuberculosis
        Tuberculosis is the major cause of AIDS-related mortality
    worldwide. Congress passed landmark legislation--the Comprehensive
    Tuberculosis Elimination Act of 2008--Public Law 110-873 last year that
    authorizes a number of actions that will shore up State TB control
    programs, enhance U.S. capacity to deal with the serious threat of
    drug-resistant tuberculosis and escalate our efforts to develop
    urgently needed new ``tools'' in the form of drugs, diagnostics, and
    vaccines. It is critical that the $210 million in funding authorized
    for fiscal year 2010 in this important new law is appropriated for the
    CDC Division of TB Elimination. This represents an increase of $66.1
    million more than current funding levels. Funding to support the
    prevention, control, and elimination of tuberculosis must increase
    substantially if we are going to make headway against this deadly
    disease and to address the emerging threat of highly drug resistant
    tuberculosis.
                              cdc--viral hepatitis
        Funds are urgently needed to provide core public health services
    and to track chronic cases of hepatitis. Hepatitis is a serious co-
    infection for nearly one-third of our HIV patients. We strongly urge
    you to boost funding for viral hepatitis at the CDC by $31 million for
    a total funding of $50 million.
      hiv/aids bureau of the health resources and services administration
        We strongly urge you to increase funding for the Ryan White program
    by $577 million in fiscal year 2010 with at least an increase of $68.4
    million for part C for a total appropriation of $270,254,000. We also
    strongly support the $4 million included in the President's budget to
    support in-depth, long-term HIV training opportunities for primary care
    clinicians.
        Ryan White part C funds comprehensive HIV care and treatment--the
    services that are directly responsible for the dramatic decreases in
    AIDS-related mortality and morbidity over the last decade. While the
    patient load in part C programs has been rising in number, funding for
    part C has effectively decreased. Part C programs expect a continued
    increase in patients due to higher diagnosis rates and declining
    insurance coverage. During this economic downturn people with HIV
    across the country will rely on part C comprehensive services more than
    ever. An increase in funding is critical to ensure that clinics are
    able to prevent staffing cuts, as well as, to ensure the public health
    of our communities. Part C of the Ryan White program has been under-
    funded for years, but new pressures are creating a crisis in
    communities across the country. The HIV medical clinics funded through
    part C have been in dire need of increased funding for years. Years of
    near flat funding, combined with large increases in the patient
    population, are negatively impacting the ability of part C providers to
    serve their patients.
        With the rapid cost increases in all aspects of healthcare
    delivery, despite small funding increases, programs are still operating
    at a funding deficit because they are serving more patients than ever.
    In 2008, part C programs will treat an estimated 248,070--a dramatic 30
    percent increase in less than 10 years. Part C clinics are laying off
    staff, discontinuing critical services such as laboratory monitoring,
    creating waitlists, and operating on a 4-day work week just to get by.
    HIVMA strongly supports the effort led by the Ryan White Medical
    Providers Coalition to double funding for Ryan White part C programs by
    fiscal year 2012. These funds are urgently critical to meet the needs
    of HIV patients served by part C around the country.
        The $4 million proposed in the President's budget to support
    longer-term training opportunities in HIV medicine or clinical HIV
    fellowships for primary care practitioners is vital to drawing
    clinicians into the field of HIV medicine and ensuring new HIV
    clinicians have the skills and expertise to provide effective HIV care.
    More that a one-quarter of a century into the HIV epidemic, we are
    seeing the graying of our Nation's HIV clinical workforce, and we have
    serious concerns about ensuring a new generation of HIV medical
    providers to care for Americans with HIV. In a recent survey of Ryan
    White part C clinics--nearly 70 percent reported difficulty recruiting
    and retaining HIV clinicians. One of the top barriers identified to
    retention and to recruitment was lack of a qualified workforce. We must
    promptly and swiftly address this issue before its effects are felt in
    increases in morbidity and mortality from HIV and the proposed $4
    million for more intensive training in HIV medicine would be an
    important first step.
        We also respectfully urge you to include at least $1 million in
    this year's Labor, Health and Human Services, and Education, and
    Related Agencies appropriations bill for a study to evaluate the
    capacity of the HIV medical workforce as well as potential strategies
    to increase the numbers of young physicians, nurse practitioners and
    physician assistants entering HIV medicine.
          national institutes of health (nih)--office of aids research
        HIVMA strongly supports an increase of at least $3.7 billion for
    all research programs at the NIH, including at least a $500 million
    increase for the NIH Office of AIDS. This level of funding is vital to
    sustain the pace of research that will improve the health and quality
    of life for millions of Americans.
        HIVMA strongly supported the infusion of NIH research dollars
    included in the economic recovery bill. The desperately needed funding
    came at a critical time to sustain our Nation's scientific research
    capacity while stimulating the economy in communities across the
    country.
        Prior to the boost in NIH funding, the declining U.S. investment in
    biomedical research had taken its toll in deep cuts to clinical trials
    networks and significant reductions in the numbers of high-quality,
    investigator-initiated grants that were approved. With only 1 in 4
    research applications receiving funding, the pipeline for critical
    discoveries and HIV scientists has been dwindling and our role as a
    leader in biomedical research is at serious risk.
        Our past investment in a comprehensive portfolio was responsible
    for the dramatic gains that we made in our HIV knowledge base, gains
    that resulted in reductions in mortality from AIDS of nearly 80 percent
    in the United States and in other countries where treatment is
    available. Gains that also helped us to reduce the mother to child HIV
    transmission rate from 25 percent to nearly 1 percent in the United
    States and to very low levels in other countries where treatment is
    available.
        A continued robust AIDS research portfolio is essential to sustain
    and to accelerate our progress in offering more effective prevention
    technologies; developing new and less toxic treatments; and supporting
    the basic research necessary to continue our work developing a vaccine
    that may end the deadliest pandemic in human history. The sheer
    magnitude of the number of people affected by HIV--more than 1 million
    people in the United States; more than 33 million people globally--
    demands a continued investment in AIDS research if we are going to
    truly eradicate this devastating disease. We believe a high priority
    should be research to discover novel prevention strategies, to improve
    available treatment strategies, to aid prevention and to maximize the
    benefits of antiretroviral therapy, especially in the populations
    disproportionately affected by HIV in the United States and in
    resource-limited settings.
        We also continue to support the NIH's Fogarty International Center
    (FIC) and recommend an expansion of its programs and funding. The FIC
    training programs play a critical role in developing self-sustaining
    healthcare infrastructures in resource-limited countries. These
    important programs offer invaluable training and mentoring to
    indigenous physicians from the countries hardest hit by the HIV
    pandemic and other deadly infectious diseases, such as malaria and
    tuberculosis. Physicians trained through the FIC are able to develop
    research programs that more effectively address the healthcare,
    cultural and resource needs of their country's residents while also
    fostering the development of ongoing, robust research and clinical
    programs.
        Historically, our Nation has made significant strides in responding
    to the HIV pandemic here at home and around the world, but we have lost
    ground in recent years, particularly domestically, as funding
    priorities have shifted away from public health and research programs.
    We appreciate the many difficult decisions that Congress faces this
    year but urge you to recognize the importance of investing in HIV
    prevention, treatment, and research now to avoid the much higher cost
    that individuals, communities, and broader society will incur if we
    fail to sustain these programs now. We have the opportunity to limit
    the toll of this deadly infectious disease on our planet and to save
    the lives of millions who are infected or at risk of infection here in
    the United States and around the globe.
                                     ______

                        Letter From the HIV Law Project
                                            New York, NY, May 22, 2009.
    Hon. Tom Harkin,
    Chairman, Subcommittee on Labor, Health, and Human Services, and
            Education, and Related Agencies, Washington, DC.
        Dear Chairman Harkin: We respectfully request that you eliminate
    all funding for abstinence-only-until-marriage programs (in particular
    the Community-Based Abstinence Education Program as well as the Title V
    Abstinence Education Programs), and instead fund programs that provide
    medically accurate, age-appropriate comprehensive sex education.
        President Obama has recently released a budget that zeroes out
    these funding streams for abstinence-only-until-marriage programs. We
    applaud his leadership in stopping the flow of dollars that has funded
    these ineffective and inaccurate programs for too long. Yet the
    President's budget proposes to replace these programs with a new Teen
    Pregnancy Prevention Initiative that falls short of the needed
    comprehensive sexuality education programming, and opens the door to
    again funding ineffectual abstinence-only programs with new dollars.
        Moving forward, we ask that you follow President Obama's lead in
    advancing public health over ideology by embracing evidence- and
    science-based educational programs through the elimination of funding
    for abstinence-only programs. But we believe that new funds to protect
    the sexual and reproductive health of adolescents through educational
    programming must be comprehensive in nature, and not limited to the
    single issue of teen pregnancy prevention.
                   what is comprehensive sexuality education?
        Comprehensive sexuality education programs include age-appropriate,
    medically accurate information on a wide range of topics related to
    sexuality including relationships, decisionmaking, abstinence,
    contraception, and disease prevention. They provide students with
    opportunities for developing interpersonal and relationship skills as
    well as learning accurate information. Comprehensive sexuality
    education programs help young people exercise responsibility regarding
    sexual relationships by addressing abstinence, pressures to engage in
    sexual intercourse prematurely, and the use of contraception.
    Comprehensive sexuality education also addresses prevention against the
    triple threats of unwanted teen pregnancies, sexually transmitted
    infections, and HIV in order to preserve the sexual and reproductive
    health of our young people.
            abstinence-only programs are ineffective and inaccurate
        Contrary to the claims of abstinence-only proponents, these
    programs have had no positive impact on teen sexuality. A study
    commissioned by the U.S. Department of Health and Human Services found
    that youth who participated in abstinence-only programs were no more
    likely than their peers to abstain from sex, and participants reported
    having similar numbers of sexual partners and having initiated sex at
    the same average age as their counterparts who did not participate in
    the programs.\1\
    ---------------------------------------------------------------------------
        \1\ Trenholm, Christopher, Barbara Devaney, Ken Fortson, et al. for
    Mathematica Policy Research. ``Impacts of Four Title V, Section 510
    Abstinence Education Programs. Final Report.'' April 2007. Available at
    http://www.mathematica-mpr.com/publications/PDFs/impactabstinence.pdf
    ---------------------------------------------------------------------------
        Teaching abstinence is appropriate if discussed as one among many
    possible approaches to staying healthy, and avoiding unintended
    pregnancy. The problem is teaching abstinence only. Abstinence-only-
    until-marriage programs are prohibited from teaching about
    contraceptives, except to emphasize their failure rates. Many of the
    most popular federally funded, abstinence-only curricula are rife with
    false and misleading information, including that condoms fail to
    prevent the spread of HIV approximately 31 percent of the time in
    heterosexual sex, and that HIV is spread through sweat and tears. By
    their very definition, abstinence-only programs perpetuate ignorance as
    well as homophobia by teaching that a mutually faithful monogamous
    relationship in the context of marriage is the expected standard of
    sexual activity, and that sexual activity outside of the context of
    marriage is likely to have harmful psychological and physical effects.
            comprehensive sexuality education programs are effective
        A rigorous review of 48 studies evaluating the efficacy of domestic
    comprehensive sexuality education programs found numerous positive
    outcomes, and debunked all the myths that serve to hamper governmental
    support of comprehensive sexuality education:\2\
    ---------------------------------------------------------------------------
        \2\ Douglas Kirby, Ph.D. et al. ``Emerging Answers 2007: Research
    Findings on Programs to Reduce Teen Pregnancy and Sexually Transmitted
    Diseases.'' November 2007. Available at http://
    www.thenationalcampaign.org/EA2007/EA2007_full.pdf
    ---------------------------------------------------------------------------
      --Comprehensive sexuality education program participants were found
            to delay sexual initiation in 40 percent of the programs
            reviewed, and no study found that comprehensive sexuality
            education programs hasten the initiation of sex.
      --Of the studies that measured the programs' impact on frequency of
            sexual activity among participants, 30 percent found that
            programs reduced the frequency of sexual activity, and none
            found an increase in frequency.
      --A decrease in the number of sexual partners was documented by 41
            percent of those studies measuring for this.
      --An increase in condom use among program participants was found by
            41 percent of the studies.
      --56 percent of the programs found that sexuality and STD/HIV
            education programs significantly reduced sexual risk-taking.
            Reducing risk-taking reduces the transmission of STIs and HIV,
            and helps to prevent unwanted pregnancies. None of the programs
            increased sexual risk-taking.
      --One of the studies estimated the cost-effectiveness of a sex
            education program, and found that for every $1 invested in the
            comprehensive sexuality program studied, $2.65 was saved in
            medical and social costs, attributable to pregnancy prevention
            and prevention of the transmission of sexually transmitted
            infections, including HIV.
                the public supports comprehensive sex education
        A 2004 poll by Harvard's Kennedy School of Government, the Kaiser
    Family Foundation, and National Public Radio found that 77 percent of
    Americans believe that giving teens information about how to obtain and
    use condoms makes it more likely that teens will practice safe sex now
    or in the future. Further, a mere 7 percent of Americans said sex
    education should not be taught in schools.\3\
    ---------------------------------------------------------------------------
        \3\ National Public Radio, Kaiser Family Foundation, and Kennedy
    School of Government, ``Sex Education in America: General Public/
    Parents Survey.'' January 2004. Available at http://www.kff.org/
    newsmedia/upload/Sex-Education-in-America-Summary.pdf
    ---------------------------------------------------------------------------
                           youth are sexually active
        One of the fundamental problems with abstinence-only programs is
    that they ignore the reality of teenage sexuality. According to the
    Centers for Disease Control and Prevention, in 2007, 47 percent of high
    school students had sex at some time. In addition, nearly 15 percent of
    students had sex with four or more sexual partners.\4\ Further, that
    same year 38 percent of high school students who were then sexually
    active had not used a condom during last sexual intercourse. In other
    words, sexually active youth are engaging in risky sexual behaviors.
    ---------------------------------------------------------------------------
        \4\ Centers for Disease Control and Prevention. ``Youth Risk
    Behavior Surveillance--United States, 2007''. June 6, 2008. Available
    at: http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5704a1.htm
    ---------------------------------------------------------------------------
               negative health outcomes are prevalent among youth
      --Almost half of all new STD infections are among youth aged 15 to
            24.
      --Approximately 14 percent of the persons diagnosed with HIV/AIDS in
            2006 were young people, between the ages of 13 and 24.
      --In 2002, there were approximately 757,000 pregnancies among
            adolescents aged 15-19.\5\
    ---------------------------------------------------------------------------
        \5\ Centers for Disease Control and Prevention, ``Sexual Risk
    Behaviors''. Available at http://www.cdc.gov/healthyyouth/
    sexualbehaviors/index.htm
    ---------------------------------------------------------------------------
        Comprehensive sex education has great potential to influence safer
    sexual behavior among youth and reduce the risk of HIV and STI
    transmission, as well as prevent unwanted pregnancies. Yet many young
    people still lack both the knowledge and the skills to minimize their
    risk. Prevention is not possible without knowledge of risk and
    appropriate risk-reduction strategies.
     schools are failing to educate students about sexual and reproductive
                                     health
        Unfortunately, recent history indicates that young people are
    becoming less able to protect themselves due to their schools' failure
    to provide comprehensive sexuality education. In 2006, only 38.5
    percent of high schools provided students with information regarding
    proper condom use,\6\ a decrease from 2000 when 55.1 percent of high
    schools provided this information.\7\ Additionally, while 96 percent of
    States provided funding for or offered staff development on HIV
    prevention to health educators in 2000, only 84 percent did so in
    2006.\8\
    ---------------------------------------------------------------------------
        \6\ SHPPS 2006. ``HIV Prevention''. Available at: http://
    www.cdc.gov/HealthyYouth/SHPPS/2006/factsheets/pdf/
    FS_HIVPrevention_SHPPS2006.pdf
        \7\ SHPPS 2000. ``Fact Sheet: HIV Prevention''. Available at:
    http://www.cdc.gov/HealthyYouth/SHPPS/2000/factsheets/pdf/hiv.pdf
        \8\ SHPPS 2006. ``HIV Prevention''.
    ---------------------------------------------------------------------------
        In sum, young people need prevention information and skills in
    order to make healthy decisions. Funding for abstinence-only
    programming, which has been proven ineffective, must be eliminated and
    replaced with funds for comprehensive sexuality education. We cannot
    afford to continue to spend money on ineffective programs. Our young
    people deserve, and it is Government's obligation to provide, programs
    that give them the information they need to make responsible decisions
    to maintain their own sexual and reproductive health.
                Sincerely yours,
                        ADAP Advocacy Association; African Services
                                Committee; AIDS Alabama; AIDS Alliance for
                                Children, Youth and Families; AIDS Law
                                Project of Pennsylvania; Alliance of AIDS
                                Services--Carolina; Cascade AIDS Project;
                                Center for HIV Law & Policy; Center for
                                Women & HIV Advocacy at HIV Law Project;
                                CHAMP.
                        Christie's Place; Colorado AIDS Project; Community
                                Access National Network; Global Life Works;
                                HIVictorious, Inc.; Housing Works; Positive
                                Women's Network; Latino Commission on AIDS;
                                Lifelong AIDS Alliance; National Alliance
                                of State and Territorial AIDS Directors.
                        New York City AIDS Housing Network (NYCAHN);
                                Sisterlove; SMART (Sisterhood Mobilized for
                                AIDS/HIV Research & Treatment); The Women's
                                Collective; Women's HIV Collaborative of
                                New York; Women's Initiative to Stop HIV--
                                NY of the Legal Action Center; Women's
                                Lighthouse Project; Women Organized to
                                Respond to Life-Threatening Diseases
                                (WORLD); Young Women of Color HIV/AIDS
                                Coalition.
                                     ______

                        Prepared Statement of HONOReform
        Mr. Chairman and members of the subcommittee: As president and
    cofounder of Hepatitis Outbreaks National Organization for Reform
    (HONOReform), I want to take this opportunity to thank you for the
    leadership role this subcommittee has played on healthcare acquired
    infections (HAIs). HONOReform is a nonprofit foundation that advances
    the lessons learned in hepatitis outbreaks and seeks to prevent future
    healthcare-associated hepatitis epidemics through education and policy
    reform.
        The Centers for Disease Control and Prevention (CDC) estimates
    there are 1.7 million infections resulting in approximately 99,000
    deaths annually in the United States, making HAIs the fourth-leading
    cause of death. Beyond the human toll, there is an enormous financial
    burden to our healthcare system.
        We are deeply concerned with the rise in the number of disease
    outbreaks related to the reuse of syringes and misuse of multidose
    vials in the outpatient setting. In the January 2009 edition of the
    Annals of Internal Medicine, an article by the CDC, revealed the
    occurrence of 33 outbreaks of viral hepatitis in healthcare settings
    over the last decade. All of these documented outbreaks occurred in
    nonhospital settings and involved failure on the part of healthcare
    providers to adhere to basic infection control practices, most notably
    by reusing syringes and other equipment intended for single use.
        I am a victim of what was the largest single source outbreak of
    Hepatitis C in U.S. history, until last year's Las Vegas, Nevada
    outbreak that potentially exposed more than 63,000 patients to
    hepatitis C. In 2001, I contracted hepatitis C through an oncology
    clinic (nonhospital setting), in Fremont, Nebraska as I was fighting to
    survive breast cancer for the second time. Ninety-eight other patients
    from the oncology clinic became infected with hepatitis C. The nurse
    would reuse the syringe for port flushes, which would then contaminated
    a 500cc saline bag. The saline bag was used for other patients, which
    in turn became the source of infection for multiple cancer patients.
    This improper practice was repeated on a regular basis over a 2-year
    period.
        I utilized my malpractice settlement to establish HONOReform in
    2007 to put an end to these completely preventable outbreaks. More than
    100,000 patients seeking healthcare and treatment have received letters
    notifying them of potential exposure to hepatitis and HIV due to
    improper injection practices in the last 10 years. In April 2009, two
    outbreaks in New Jersey--a cancer clinic and hospital--and an outbreak
    at a South Dakota outpatient urology clinic, conducted large patient
    notifications which further illustrates that this problem requires
    immediate action to protect the citizens that are accessing our
    healthcare system each day.
        Moreover, these hepatitis outbreaks are entirely preventable when
    healthcare providers adhere to proper infection control procedures. A
    2002 study by the American Association of Nurse Anesthetists (AANA)
    found that 1 percent of practitioners felt it was acceptable to reuse a
    syringe for multiple patients and more than 30 percent of healthcare
    providers believed it was acceptable to reuse a syringe on the same
    patient if the needle is changed.
        Mr. Chairman, beyond the significant risk posed to the physical
    health of patients, even the receipt of a notification of potential
    exposure can cause significant mental anguish and lead to an even
    greater danger--a loss of faith in the medical system by the public.
    Victims feel that they have been personally violated and betrayed by
    those to whom they entrusted their health. We, as a Nation, can not
    afford to ignore the issue and hope it goes away.
        Through its foundation, HONOReform has joined forces with the
    Accreditation Association for Ambulatory Health Care, AANA, Association
    for Professionals in Infection Control and Epidemiology, Ambulatory
    Surgery Foundation, Becton, Dickinson and Company, CDC, CDC Foundation,
    Nebraska Medical Association, and the Nevada State Medical Association,
    to establish the One & One Campaign. The One & Only Campaign is an
    effort aimed at re-educating healthcare providers that syringes and
    other medical equipment must not be reused and empowering patients to
    ask the right questions when seeking healthcare. If patients are
    knowledgeable about injection safety, they will be empowered to speak
    up in their provider's office to ask if they are getting ``One Needle,
    One Syringe, and Only One Time.
        In fiscal year 2009, the CDC received $2.5 million to establish a
    pilot campaign in Nevada for the launch of the One & Only Campaign,
    which we hope will be expanded to the national campaign with your
    support for continued and expanded funding in fiscal year 2010.
        Each of these requests will have a profound impact on all patients
    and consumers. They are aimed at reducing the knowledge gap for
    providers, empowering patients, tracking HAIs to limit the spread of
    disease, and improving the quality and standards of care in our
    Nation's ambulatory care facilities. By focusing on prevention, this
    subcommittee can realize savings for healthcare systems and promote
    increased patient safety for all Americans.
        Mr. Chairman, we respectfully request that the subcommittee
    continue supporting prevention efforts at CDC, HHS, and the Agency for
    Healthcare Research and Quality (AHRQ) to help prevent future hepatitis
    and HIV outbreaks through the following fiscal year 2010 appropriations
    requests:
        HONOReform requests $26 million for CDC's Division of Healthcare
    Quality and Promotion to build infrastructure for complete and
    consistent adherence to injection safety and infection control
    guidelines in the delivery of outpatient care.
        As you know, the migration of healthcare delivery from primarily
    acute care hospitals to other nonhospital settings (e.g., home care,
    ambulatory care, free-standing specialty care sites, long-term care,
    etc.) requires that common principles of infection control practice be
    applied to the spectrum of healthcare delivery settings. The CDC needs
    additional resources to use the knowledge gained through these
    activities to detect infections and develop new strategies to prevent
    healthcare-associated transmission of blood borne pathogens. This
    request includes the following elements:
      --Provider Education and Awareness.--Nine million dollars to be used
            to support CDC's efforts around provider education and patient
            awareness activities. Currently, the CDC along with patient
            advocacy organizations, foundations, provider associations and
            societies and industry partners have established the Safe
            Injection Practices Coalition. The requested funding would be
            used to roll out a national public health campaign focused on
            safe injection practices. Additionally, funds will be used to
            develop and disseminate safe practice materials and develop
            related tools designed for inpatient and outpatient settings.
            Innovative tools will be developed in conjunction with key
            partners and stakeholders for use by providers and healthcare
            personnel, including training tools to be used by professional
            organizations and accreditation and licensing groups to
            increase adherence to recommendations
      --Engineering and Innovation.--Eight million dollars would be used to
            support CDC in promoting private-sector healthcare solutions to
            injection safety and infection control problems by engage and
            incentivizing the private sector to innovate and create fast
            track engineering solutions to injection safety and infection
            control problems through the development of innovative products
            to reduce infection transmission for inpatient and outpatient
            healthcare settings. With this funding, CDC will convene a
            roundtable with industry, conduct a study on available
            technology, assess opportunities for investment in research and
            development, and examine incentives required for adoption of
            equipment designed with engineering controls (e.g., sharps
            disposal containers, self-sheathing needles, safer medical
            devices, such as sharps with engineered sharps injury
            protections and needless systems, etc.). CDC will also pursue
            mechanisms such as grants or CRADAs with industry to accelerate
            the development of products that have the potential for
            eliminating the opportunity for human error from process of
            administering injections.
      --Detection and Tracking.--Nine million dollars would be used for
            detection and tracking in order to enable States to investigate
            outbreaks of hepatitis and other potential pathogens related to
            injection safety. In addition, this funding would provide
            support to CDC for emergency response to assist States in
            responding to hepatitis outbreaks (i.e., Nevada), including
            genetic sequencing tests. Funding would support efforts
            including training at health departments related to safe
            injection practices and recognition of errors, and to enable
            rapid investigation and intervention when errors are detected.
            The funding would also support the augmentation of survey
            capacity in outpatient settings to strengthen State capacity to
            detect infections that indicate systemic patient safety errors.
            The funding will enable CDC to provide support to States by
            providing training tools for surveyors, health department staff
            and epidemiologists to improve methods of monitoring adherence
            to correct practices and to provide tools for investigation,
            response and intervention strategies. Funds will also enable
            CDC to provide data analysis and feedback to States.
        HONOReform requests $1 million for the Department of Health and
    Human Services (HHS) to expand its current focus for reducing
    healthcare acquired infections (HAIs) from hospitals to all healthcare
    settings, including outpatient facilities. We are deeply concerned with
    the number of HAIs occurring in office-based settings, such as
    ambulatory care centers, infusion centers, and endoscopy clinics, due
    to a lack of adherence to basic infection control procedures. In the
    past year, more than 100,000 patients across the country have been
    exposed to hepatitis and HIV from healthcare providers failing to
    adhere to proper safe injection practices and infection control.
        HONOReform requests $10 million in general patient safety funds for
    the AHRQ's Ambulatory Patient Safety Program. While much is known about
    risk and hazards in the hospital setting, the same cannot be said of
    ambulatory care setting. Few safety practices have been identified, and
    there is limited data on the nature of risk and hazards to patients and
    the threat to quality in the ambulatory care setting. As part of the
    overall AHRQ patient safety and quality improvement efforts, the
    identification, assessment, and modeling of risk and hazards prior to
    designing or implementing intervention strategy in ambulatory care is
    critical. In light of the growing number of incidents involving syringe
    reuse and hepatitis C transmission, this funding would enable AHRQ to
    expand its ambulatory safety and quality program ``to identify the
    inherent risks in ambulatory settings and to develop potential
    solutions for protecting patients.''
        Mr. Chairman, on behalf of HONOReform, I would like to express my
    appreciation for this opportunity to present written testimony before
    the subcommittee. The growing number of incidents involving syringe
    reuse and hepatitis C transmission in non-hospital settings across the
    country highlights the need for enhancing education, awareness and
    public health activities related to proper infection control and safe
    injection practices.
                                     ______

      Prepared Statement of the Health Professions and Nursing Education
                                   Coalition
        The members of the Health Professions and Nursing Education
    Coalition (HPNEC) are pleased to submit this statement for the record
    in support of $550 million in fiscal year 2010 for the health
    professions education programs authorized under titles VII and VIII of
    the Public Health Service Act and administered through the Health
    Resources and Services Administration (HRSA). HPNEC is an informal
    alliance of more than 60 national organizations representing schools,
    programs, health professionals, and students dedicated to ensuring the
    healthcare workforce is trained to meet the needs of our diverse
    population.
        As you know, the title VII and VIII health professions and nursing
    programs are essential components of the Nation's healthcare safety
    net, bringing healthcare services to our underserved communities. These
    programs support the training and education of healthcare providers to
    enhance the supply, diversity, and distribution of the healthcare
    workforce, filling the gaps in the supply of health professionals not
    met by traditional market forces. Through loans, loan guarantees, and
    scholarships to students, and grants and contracts to academic
    institutions and nonprofit organizations, the title VII and VIII
    programs are the only Federal programs designed to train providers in
    interdisciplinary settings to meet the needs of special and underserved
    populations, as well as increase minority representation in the
    healthcare workforce.
        We are thankful to the subcommittee for the $200 million provided
    for the health professions programs in the American Recovery and
    Reinvestment Act (Public Law 111-5). We also greatly appreciate that
    the recently enacted fiscal year 2009 Omnibus Appropriations bill
    (Public Law 111-8) provides some increases for most title VII and VIII
    programs. These investments provide a crucial springboard to begin to
    wholly reverse chronic underfunding of these programs and address
    existing and looming shortages of health professionals.
        According to HRSA, an additional 30,000 health practitioners are
    needed to alleviate existing health professional shortages. Combined
    with faculty shortages across health professions disciplines, racial/
    ethnic disparities in healthcare, and a growing, aging population,
    these needs strain an already fragile healthcare system. Because of the
    time required to train health professionals, we must make appropriate
    investments today. Yet, despite some increases in recent years, many of
    the health professions programs remain well below their comparable
    fiscal year 2005 funding levels. HPNEC's $550 million recommendation
    will help sustain the health workforce expansion supported by funding
    in the recovery package. Further, this appropriation will restore
    funding to critical programs that sustained drastic funding reductions
    in fiscal year 2006 and remain well below fiscal year 2005 levels.
        We are grateful to President Obama for highlighting the need to
    strengthen the health professions workforce as a national priority.
    This strategy is in line with numerous recent, highly regarded
    recommendations. In a December 2008 Institute of Medicine (IOM) report,
    HRSA's health professions programs were characterized as ``an
    undervalued asset'' and the Department of Health and Human Services was
    encouraged to support additional investments in the programs. Another
    IOM report on the future workforce for older Americans from April 2008
    also called for increased funding for the health professions programs.
    The November 2008 issue of the peer-reviewed journal Academic Medicine
    chronicles the effectiveness of the programs, and the primary care
    programs in particular, while the December 2008 issue of the Mt. Sinai
    Journal of Medicine highlights the impact of the diversity programs.
    These most recent publications showcase the network of title VII and
    VIII initiatives across the country supporting the education and
    training of the full range of health providers. Together, the programs
    work in concert with other programs at the Department of Health and
    Human Services--including the National Health Service Corps and
    Community Health Centers (CHCs)--to strengthen the health safety net
    for rural and medically underserved communities.
        The Health Professions Education Partnerships Act of 1998 (Public
    Law 105-392) consolidated the programs into seven general categories:
      --The purpose of the Minority and Disadvantaged Health Professionals
            Training programs is to improve healthcare access in
            underserved areas and the representation of minority and
            disadvantaged healthcare providers in the health professions.
            Minority Centers of Excellence support programs that seek to
            increase the number of minority health professionals through
            increased research on minority health issues, establishment of
            an educational pipeline, and the provision of clinical
            opportunities in community-based health facilities. The Health
            Careers Opportunity Program seeks to improve the development of
            a competitive applicant pool through partnerships with local
            educational and community organizations. The Faculty Loan
            Repayment and Faculty Fellowship programs provide incentives
            for schools to recruit underrepresented minority faculty. The
            Scholarships for Disadvantaged Students (SDS) make funds
            available to eligible students from disadvantaged backgrounds
            who are enrolled as full-time health professions students.
            Nurses received $15.1 million in fiscal year 2007 from SDS
            grants, 32 percent of funds appropriated for SDS.
      --The Primary Care Medicine and Dentistry programs, including General
            Pediatrics, General Internal Medicine, Family Medicine, General
            Dentistry, Pediatric Dentistry, and Physician Assistants,
            provide for the education and training of primary care
            physicians, dentists, and physician assistants to improve
            access and quality of healthcare in underserved areas. Two-
            thirds of all Americans interact with a primary care provider
            every year. Approximately one- half of primary care providers
            trained through these programs go on to work in underserved
            areas, compared to 10 percent of those not trained through
            these programs. The General Pediatrics, General Internal
            Medicine, and Family Medicine programs provide critical funding
            for primary care training in community-based settings and have
            been successful in directing more primary care physicians to
            work in underserved areas. They support a range of initiatives,
            including medical student training, residency training, faculty
            development and the development of academic administrative
            units. The General Dentistry and Pediatric Dentistry programs
            provide grants to dental schools and hospitals to create or
            expand primary care dental residency training programs.
            Recognizing that all primary care is not only provided by
            physicians, the primary care cluster also provides grants for
            Physician Assistant programs to encourage and prepare students
            for primary care practice in rural and urban Health
            Professional Shortage Areas. Additionally, these programs
            enhance the efforts of osteopathic medical schools to continue
            to emphasize primary care medicine, health promotion, and
            disease prevention, and the practice of ambulatory medicine in
            community-based settings.
      --Because much of the Nation's healthcare is delivered in areas far
            removed from health professions schools, the Interdisciplinary,
            Community-Based Linkages cluster provides support for
            community-based training of various health professionals. These
            programs are designed to provide greater flexibility in
            training and to encourage collaboration between two or more
            disciplines. These training programs also serve to encourage
            health professionals to return to such settings after
            completing their training. The Area Health Education Centers
            (AHECs) provide clinical training opportunities to health
            professions and nursing students in rural and other underserved
            communities by extending the resources of academic health
            centers to these areas. AHECs, which have substantial State and
            local matching funds, form networks of health-related
            institutions to provide education services to students, faculty
            and practitioners. Geriatric Health Professions programs
            support geriatric faculty fellowships, the Geriatric Academic
            Career Award, and Geriatric Education Centers, which are all
            designed to bolster the number and quality of healthcare
            providers caring for our older generations. Given America's
            burgeoning aging population, there is a need for specialized
            training in the diagnosis, treatment, and prevention of disease
            and other health concerns of the elderly. The Quentin N.
            Burdick Program for Rural Health Interdisciplinary Training
            places an emphasis on long-term collaboration between academic
            institutions, rural healthcare agencies, and providers to
            improve the recruitment and retention of health professionals
            in rural areas. This program has received no funding since
            fiscal year 2006. The Allied Health Project Grants program
            represents the only Federal effort aimed at supporting new and
            innovative education programs designed to reduce shortages of
            allied health professionals and create opportunities in
            medically underserved and minority areas. Health professions
            schools use this funding to help establish or expand allied
            health training programs. The need to address the critical
            shortage of certain allied health professionals has been
            acknowledged repeatedly. For example, this shortage has
            received special attention given past bioterrorism events and
            efforts to prepare for possible future attacks. The Graduate
            Psychology Education Program provides grants to doctoral,
            internship and postdoctoral programs in support of
            interdisciplinary training of psychology students with other
            health professionals for the provision of mental and behavioral
            health services to underserved populations (i.e., older adults,
            children, chronically ill, and victims of abuse and trauma,
            including returning military personnel and their families),
            especially in rural and urban communities.
      --The Health Professions Workforce Information and Analysis program
            provides grants to institutions to collect and analyze data on
            the health professions workforce to advise future
            decisionmaking on the direction of health professions and
            nursing programs. The Health Professions Research and Health
            Professions Data programs have developed a number of valuable,
            policy-relevant studies on the distribution and training of
            health professionals, including the Eighth National Sample
            Survey of Registered Nurses, the Nation's most extensive and
            comprehensive source of statistics on registered nurses.
            However, the Workforce Information and Analysis program has
            received no appropriation since fiscal year 2006.
      --The Public Health Workforce Development programs are designed to
            increase the number of individuals trained in public health, to
            identify the causes of health problems, and respond to such
            issues as managed care, new disease strains, food supply, and
            bioterrorism. The Public Health Traineeships and Public Health
            Training Centers seek to alleviate the critical shortage of
            public health professionals by providing up-to-date training
            for current and future public health workers, particularly in
            underserved areas. Preventive Medicine Residencies, which
            receive minimal funding through Medicare GME, provide training
            in the only medical specialty that teaches both clinical and
            population medicine to improve community health. Dental Public
            Health Residency programs are vital to the Nation's dental
            public health infrastructure. The Health Administration
            Traineeships and Special Projects grants are the only Federal
            funding provided to train the managers of our healthcare
            system, with a special emphasis on those who serve in
            underserved areas. However, the traineeships have received no
            appropriation since fiscal year 2006.
      --The Nursing Workforce Development programs under title VIII provide
            training for entry-level and advanced degree nurses to improve
            the access to, and quality of, healthcare in underserved areas.
            These programs provide the largest source of Federal funding
            for nursing education, providing loans, scholarships,
            traineeships, and programmatic support to 51,657 nursing
            students and nurses in fiscal year 2008. Healthcare entities
            across the Nation are experiencing a crisis in nurse staffing,
            caused in part by an aging workforce and capacity limitations
            within the educational system. Each year, nursing schools turn
            away between 50,000 and 88,000 qualified applications at all
            degree levels due to an insufficient number of faculty,
            clinical sites, classroom space, clinical preceptors, and
            budget constraints. At the same time, the need for nursing
            services and licensed, registered nurses is expected to
            increase significantly over the next 20 years. Congress
            responded to this dire national need by passing the Nurse
            Reinvestment Act (Public Law 107-205) in 2002, which increases
            nursing education, retention, and recruitment. The Advanced
            Education Nursing program awards grants to train a variety of
            advanced practice nurses, including nurse practitioners,
            certified nurse-midwives, nurse anesthetists, public health
            nurses, nurse educators, and nurse administrators. For example,
            this funding has been instrumental in doubling nurse anesthesia
            graduates in the last 8 years. However, even though the number
            of graduates doubled, the vacancy rate for nurse anesthetists
            has remained the same at 12 percent, due to a retiring nursing
            profession and an aging population requiring more care.
            Workforce Diversity grants support opportunities for nursing
            education for disadvantaged students through scholarships,
            stipends, and retention activities. Nurse Education, Practice,
            and Retention grants are awarded to help schools of nursing,
            academic health centers, nurse-managed health centers, State
            and local governments, and other healthcare facilities to
            develop programs that provide nursing education, promote best
            practices, and enhance nurse retention. The Loan Repayment and
            Scholarship Program repays up to 85 percent of nursing student
            loans and offers full-time and part-time nursing students the
            opportunity to apply for scholarship funds. In return these
            students are required to work for at least 2 years of practice
            in a designated nursing shortage area. The Comprehensive
            Geriatric Education grants are used to train RNs who will
            provide direct care to older Americans, develop and disseminate
            geriatric curriculum, train faculty members, and provide
            continuing education. The Nurse Faculty Loan program provides a
            student loan fund administered by schools of nursing to
            increase the number of qualified nurse faculty.
      --The loan programs under Student Financial Assistance support needy
            and disadvantaged medical and nursing school students in
            covering the costs of their education. The Nursing Student Loan
            (NSL) program provides loans to undergraduate and graduate
            nursing students with a preference for those with the greatest
            financial need. The Primary Care Loan (PCL) program provides
            loans covering the cost of attendance in return for dedicated
            service in primary care. The Health Professional Student Loan
            (HPSL) program provides loans covering the cost of attendance
            for financially needy health professions students based on
            institutional determination. The NSL, PCL, and HPSL programs
            are funded out of each institution's revolving fund and do not
            receive Federal appropriations. The Loans for Disadvantaged
            Students (LDS) program provides grants to health professions
            institutions to make loans to health professions students from
            disadvantaged backgrounds.
        These programs work collectively to fulfill their unique, three-
    pronged mission of improving the supply, diversity, and distribution of
    the health professions workforce. HPNEC members respectfully urge
    support for funding of at least $550 million for the title VII and VIII
    programs, an investment essential not only to the development and
    training of tomorrow's healthcare professionals but also to our
    Nation's efforts to provide needed healthcare services to underserved
    and minority communities. We greatly appreciate the support of the
    subcommittee and look forward to working with Members of Congress and
    the new administration to reinvest in the health professions programs
    in fiscal year 2010 and into the future.
                                     ______

                 Prepared Statement of the Home Safety Council
                                  introduction
        Chairman Harkin, Ranking Member Cochran, and members of the
    subcommittee, thank you for the opportunity to submit testimony on the
    fiscal year 2010 appropriations for the Centers for Disease Control and
    Prevention's (CDC) National Center for Injury Prevention and Control
    (NCIPC).
        I am Patricia Adkins, chief operating office and director of public
    policy for the Home Safety Council which is located in Washington, DC.
                      about the home safety council (hsc)
        The mission of the HSC is to help prevent and reduce the nearly
    20,000 deaths and 21 million medical visits each year from such hazards
    as falls, poisoning, fires and burns, choking and suffocation, and
    drowning. Through national programs, partnerships and the support of
    volunteers, HSC educates people of all ages to help keep them safer in
    and around their homes.
        Our vision for our Nation is safer homes that provide the
    opportunity for all individuals to lead healthy, active, and fulfilling
    lives.
                       increased funding for cdc's ncipc
        CDC's NCIPC has the mission of preventing injuries and violence,
    and reducing their consequences. It strives to help every American live
    his or her life to its fullest potential. Funds are utilized by NCIPC
    for intramural and extramural research and in assisting State and local
    health agencies in implementing injury prevention programs.
        HSC and a coalition of 30 like-minded nonprofit organizations are
    requesting an increase of $10 million to the ``Unintentional Injury
    Prevention'' account to begin to comprehensively address the large-
    scale growth of older adult falls.
        Ultimately, success in reducing the number and severity of older
    adult falls will be reached through partnerships with Federal, State,
    and local agencies along with the cooperation of many nongovernmental
    organizations.
        why injury prevention is a critical element of healthcare reform
        In 1998, the National Academy of Sciences stated, ``Injury is
    probably the most under-recognized public health threat facing the
    nation today.''
        Each year, injuries resulting from a wide variety of physical and
    emotional causes--motor vehicle crashes, sports trauma, violence,
    poisoning, fires, and falls--keep millions of children and adults from
    achieving their goals and making the most of their talents and
    abilities.
        This is what we know:
      --Nationally and in every State in the United States, injuries are
            the leading cause of death in the first 44 years of a person's
            life.
      --In a single year, more than 50 million injuries required medical
            attention, with an estimated total lifetime cost of $406
            billion.
      --This total lifetime cost includes $80 billion in medical care costs
            and $326 billion in productivity losses, including lost wages
            and benefits and the inability to perform normal household
            functions.
        These three statistics clearly show the consequences of injuries
    and its major burden on the healthcare system.
        Fortunately, injury research has proven that there are steps that
    can be taken to prevent injuries and increase the likelihood for full
    recovery when they do occur. By incorporating these strategies into our
    communities and everyday activities, we can help to ensure that
    Americans remain healthy and live their lives to the fullest potential.
                      protecting older adults from injury
        We all want a society where people, including our older citizens,
    can live healthy and productive lives. A key component of achieving
    this is helping older adults avoid injuries. There are actions we can
    take to prevent injuries and premature death to our parents,
    grandparents, and friends. Some of the most important include
    preventing older adults from falling and being injured in fires or
    motor vehicle crashes.
        One of the injuries affecting the quality of life for older adults
    is falls. Falls are the leading cause of fatal and nonfatal injuries
    for those 65 and older. Each year, 1.8 million older adults are treated
    in emergency departments. Every day, 5,000 adults 65 and older are
    hospitalized due to fall-related injuries, and every 35 minutes, an
    older adult dies from a fall-related injury.
        We know one of the greatest financial challenges facing the U.S.
    Government, its citizens, and their employers is the rising cost of
    healthcare services needed by older Americans. CDC reports that $80.2
    billion is spent annually for medical treatment of injuries, of which
    fully $19.2 billion ($12 billion for hospitalization, $4 billion for
    emergency department visits, and $3 billion for outpatient care) is for
    treating older adults injured by falls. That's almost one-quarter of
    all healthcare expenses for injuries each year spent on older adult
    falls and the majority of these expenses are paid by CMS through
    Medicare. If we cannot stem this rate of increase, it is projected that
    the direct treatment costs will reach $54.9 billion annually in 2020,
    at which time the cost to Medicare would be $32.4 billion.
        While falls are a threat to the health and independence of older
    adults and can significantly limit their ability to remain self-
    sufficient, the opportunity to reduce falls among older adults has
    never been better. Today there are proven interventions and strategies
    that can reduce falls and in turn help older adults live better and
    longer. Studies show that prescription medications have an effect on
    balance. A medication review and adjustment is a simple, cost-effective
    way to help prevent a fall. Additionally, older adults who actively
    participate in physical exercise and receive vision exams are at a
    lower risk for falling. These evidence-based interventions can help
    save healthcare costs and greatly improve the lives of older adults.
    The costs are small compared to the potential for savings. For every $1
    invested in a comprehensive falls prevention program for an older
    adult, it returns close to a $9 benefit to society.
                             how congress can help
        Congress took a major step forward in preventing older adult falls
    with passage of the Safety of Seniors Act of 2007 (S. 845 and Public
    Law 110-202) which authorized increased research, education, and
    demonstration projects. Further evidence of support included the
    passage of S. Res. 674 and the introduction of H. Res. 1478 for the
    first National Falls Prevention Awareness Day in September 2008. For
    the good intentions of Congress to bear fruit, an appropriation of $10
    million is needed for fiscal year 2010 for CDC's NCIPC.
        NCIPC's funding in this area is severely inadequate to address the
    scale of human suffering and the impact of falls on our healthcare
    system. Additional funding would enable NCIPC to expand research,
    evaluation of demonstrations, public education, professional education,
    and policy analysis. At present, CDC can only allocate $2 million per
    year to address a problem costing $19.2 billion a year. The benefits of
    increased funding would be enormous, vastly improving the quality of
    life for those 65 and older and greatly reducing healthcare costs for
    falls and related disabilities.
        Increased funding for older adult falls prevention efforts is
    supported by a broad-based coalition of nonprofit organizations and a
    growing number of State falls prevention coalitions that are dedicated
    to improving the safety and health of older Americans.
              cdc activity in falls prevention among older adults
        If the CDC NCIPC's falls prevention budget is increased by $10
    million, the next steps would be to:
      --Develop additional program demonstrations to test and replicate the
            most cost effective interventions to reduce the risk of falls;
      --Undertake additional extramural research into the causes of falls;
            and
      --Develop more public education programs to raise awareness about
            falls and what individuals, family members, professionals,
            nonprofit organizations, and the private sector can do to
            reduce them.
        On behalf of HSC and our supporting organizations, thank you for
    the opportunity to share our fiscal year 2010 appropriations request
    for the CDC NCIPC on the very costly, but often preventable problem of
    falls among older adults.
                                     ______

           Prepared Statement of The Humane Society Legislative Fund
        The Humane Society Legislative Fund (HSLF) supports a strong
    commitment by the Federal Government to research, development,
    standardization, validation, and acceptance of nonanimal and other
    alternative test methods. We are also submitting our testimony on
    behalf of The Humane Society of the United States and Doris Day Animal
    League, representing more than 11 million members and supporters. Thank
    you for the opportunity to present testimony relevant to the fiscal
    year 2010 budget request for the National Institute of Environmental
    Health Sciences (NIEHS) for activities of the National Toxicology
    Program Center for the Evaluation of Alternative Toxicological Test
    Methods (NICEATM), the support center for the Interagency Coordinating
    Committee for the Validation of Alternative Test Methods (ICCVAM).
    Function of the ICCVAM
        The ICCVAM performs a valuable function for regulatory agencies,
    industry, public health and animal protection organizations by
    assessing the validation of new, revised, and alternative toxicological
    test methods that have interagency application. After appropriate
    independent peer review of the test method, the ICCVAM recommends the
    test to the Federal regulatory agencies that regulate the particular
    endpoint the test measures. In turn, the Federal agencies maintain
    their authority to incorporate the validated test methods as
    appropriate for the agencies' regulatory mandates. This streamlined
    approach to assessment of validation of new, revised, and alternative
    test methods has reduced the regulator burden of individual agencies,
    provided a ``one-stop shop'' for industry, animal protection, public
    health, and environmental advocates for consideration of methods and
    set uniform criteria for what constitutes a validated test methods. In
    addition, from the perspective of animal protection advocates, ICCVAM
    can serve to appropriately assess test methods that can refine, reduce
    and replace the use of animals in toxicological testing. This function
    will provide credibility to the argument that scientifically validated
    alternative test methods, which refine, reduce or replace animals,
    should be expeditiously integrated into Federal toxicological
    regulations, requirements, and recommendations.
    History of the ICCVAM
        The ICCVAM is currently composed of representatives from the
    relevant Federal regulatory and research agencies. It was created from
    an initial mandate in the NIH Revitalization Act of 1993 for NIEHS to
    ``(a) establish criteria for the validation and regulatory acceptance
    of alternative testing methods, and (b) recommend a process through
    which scientifically validated alternative methods can be accepted for
    regulatory use.'' In 1994, NIEHS established the ad hoc ICCVAM to write
    a report that would recommend criteria and processes for validation and
    regulatory acceptance of toxicological testing methods that would be
    useful to Federal agencies and the scientific community. Through a
    series of public meetings, interested stakeholders, and agency
    representatives from all 14 regulatory and research agencies, developed
    the National Institutes of Health (NIH) Publication No. 97-3981,
    ``Validation and Regulatory Acceptance of Toxicological Test Methods.''
    This report, and subsequent revisions, has become the sound science
    guide for consideration of new, revised, and alternative test methods
    by the Federal agencies and interested stakeholders.
        After publication of the report, the ad hoc ICCVAM moved to
    standing status under the NIEHS' NICEATM. Representatives from Federal
    regulatory and research agencies and their programs have continued to
    meet, with advice from the NICEATM's Advisory Committee and independent
    peer review committees, to assess the validation of new, revised and
    alternative toxicological methods. Since then, several methods have
    undergone rigorous assessment and are deemed scientifically valid and
    acceptable.
    Request for Committee Report Language
        In 2006, the NICEATM/ICCVAM at the request of the U.S. Congress
    began a process of developing a 5-year roadmap for assertively setting
    goals to prioritize ending the use of antiquated animal tests for
    specific endpoints. The HSLF and other national animal protection
    organizations provided extensive comments on the process and priorities
    for the roadmap.
        While the stream of methods forwarded to the ICCVAM for assessment
    has remained relatively steady, it is imperative that the ICCVAM take a
    more proactive role in isolating areas where new methods development is
    on the verge of replacing animal tests. These areas should form a
    collective call by the Federal agencies that compose
        ICCVAM to fund any necessary additional research, development,
    validation, and validation assessment that is required to eliminate the
    animal methods. We also strongly urge the NICEATM/ICCVAM to closely
    coordinate research, development, and validation efforts with its
    European counterpart, the European Centre for the Validation of
    Alternative Methods (ECVAM) to ensure the best use of available funds
    and sound science. This coordination should also reflect a willingness
    by the Federal agencies comprising ICCVAM to more readily accept
    validated test methods proposed by the ECVAM to ensure industry has a
    uniform approach to worldwide chemical safety evaluation.
        We respectfully request the subcommittee consider the following
    report language for the fiscal year 2010 Senate Labor, Health and Human
    Services, and Education, and Related Agencies appropriations bill:

        ``The Committee acknowledges the publication of the NICEATM/ICCVAM
    Five-Year Plan but remains concerned by the slow pace at which federal
    agencies have moved to adopt regulations that would replace, reduce or
    refine the use of animals in testing. The Committee therefore requests
    that NICEATM/ICCVAM hold an initial workshop, based upon input received
    from a workshop steering committee with representation of scientists
    from academia, federal government, animal welfare organizations and
    industry, on ``Challenges to Incorporating Alternative Methods into US
    Federal Agency Programs.'' The Committee also requests that NICEATM/
    ICCVAM convene a workshop in fiscal year 2010 to assess the difficulty
    of obtaining high-quality relevant data for validating alternative
    methods, which is a significant barrier to validation and acceptance.
    NICEATM/ICCVAM are also urged to establish timetables for completion of
    all validation reviews that are currently under way.''

    National Institutes of Health Support for--``Toxicity Testing in the
            21st Century: A Vision and a Strategy''
        NIH has launched an ambitious collaboration with the Environmental
    Protection Agency (EPA) to dramatically transform the way drugs,
    consumer products, pesticides, and other chemicals are assessed for
    safety. The new approach will use isolated cells, molecular targets,
    and lower organisms such as roundworms, instead of laboratory animals.
    According to the NIH, the research collaboration is expected ``to
    generate data more relevant to humans; expand the number of chemicals
    that are tested; and reduce the time, money and number of animals
    involved in testing.''
        The tripartite arrangement is designed to capitalize on the NIH
    Chemical Genomics Center's high-speed, automated screening robots to
    test compounds for toxicity; the experimental toxicology expertise of
    the National Toxicology Program, which is headquartered at the NIH's
    NIEHS; and the computational toxicology capabilities at the EPA's
    National Center for Computational Toxicology.
        The Government collaboration seeks to implement a June 2007 report
    by the National Research Council (NRC) entitled Toxicity Testing in the
    21st Century: A Vision and a Strategy, which calls for a sustained,
    well-funded effort across the toxicology community to shift the
    traditional toxicity-testing paradigm away from its heavy reliance on
    animal testing and towards high-throughput systems that monitor
    perturbations in toxicity pathways.
        The Government project could be seen as a successor, with equally
    visionary possibilities for biology, to Dr. Collins and NHGRI's highly
    successful Human Genome Project. In order for the new vision to be
    fully realized within a decade, what is needed is a well-funded
    Government effort that would attract additional partners and resources
    from interested industries and overseas governments. We urge the
    subcommittee to support the efforts of the NIH to implement the NRC
    report.
                                     ______

         Prepared Statement of The Humane Society of the United States
        On behalf of The Humane Society of the United States (HSUS) and our
    11 million supporters nationwide, we appreciate the opportunity to
    provide testimony on our top funding priority for the Labor, Health and
    Human Services, and Education, and Related Agencies Appropriations
    Subcommittee in fiscal year 2010. We are also submitting our testimony
    on behalf of The Humane Society Legislative Fund (HSLF) and the Doris
    Day Animal League. Thank you for the opportunity to present testimony
    relevant for the fiscal year 2010 budget request.
        The HSUS requests that no Federal funding be appropriated for (1)
    the breeding of chimpanzees for research, or (2) the transfer of
    Government-owned chimpanzees to private hands (including endowments for
    their maintenance) unless for retirement to appropriate sanctuary. The
    basis of our request can be found below.
                      breeding of chimpanzees for research
        The National Center for Research Resources (NCRR) of the National
    Institutes of Health (NIH), responsible for the oversight and
    maintenance of federally owned chimpanzees, has announced a permanent
    end to funding the breeding of federally owned and supported
    chimpanzees primarily due to the excessive costs of lifetime care of
    chimpanzees in laboratory settings. We recently discovered that the
    Government has provided millions of dollars in recent years for
    chimpanzee breeding. Therefore, we seek to ensure that neither the NIH
    nor any other Federal agency provides funding for breeding of
    Government-owned chimpanzees due to the future financial implications
    to the Government and taxpayers of continuing to do so, particularly
    during this difficult economic time.
        The cost of maintaining chimpanzees in laboratories is exorbitant,
    totaling up to $8.5 million each year for the current population of
    approximately 500 federally owned or supported chimpanzees
    (approximately $54 per day per chimpanzee; more than $1,000,000 per
    chimpanzee's 60-year lifetime). Breeding of additional chimpanzees into
    laboratories will only perpetuate a number of burdens on the
    Government.
        The United States currently has a surplus of chimpanzees available
    for use in research due to overzealous breeding for HIV research and
    subsequent findings that they are a poor HIV model.\1\
    ---------------------------------------------------------------------------
        \1\ NRC (National Research Council) (1997) Chimpanzees in research:
    strategies for their ethical care, management and use. National
    Academies Press: Washington, D.C.
    ---------------------------------------------------------------------------
        Expansion of the chimpanzee population in laboratories only creates
    more concerns than presently exist about their quality of care.
        Use of chimpanzees in research raises strong public concerns.
             transfer of ownership of government-owned chimpanzees
        If the Government-owned and supported chimpanzees leave the Federal
    system and are transferred into private hands with an accompanying
    federally funded endowment, their lifetime support will not be
    guaranteed as required now by the CHIMP Act and their transfer to a
    suitable sanctuary will be highly unlikely. These chimpanzees will
    instead of warehoused and/or used for research for their entire
    lifetime--with the backing of the Government through an endowment. This
    will surely lead to a public outcry.
      --If private industry breeds and uses chimpanzees in invasive
            research with Federal endowment money, the private sector would
            be unfairly, and perhaps illegally, benefiting from federally
            owned ``resources'' meant for the betterment of the American
            public, not for the profit of private industry.
      --To date, the private sector has been less than fiscally responsible
            for the lifetime care of chimpanzees who they have used for
            private profit. Even in the situations where they eventually
            retire their chimpanzees, private users rarely offer financial
            compensation for their chimpanzees' lifetime care and on the
            few occasions that they have offered some financial
            compensation, it falls far short of what is actually needed.
        We instead urge the Government to transfer all 500 Government-owned
    chimpanzees to the national sanctuary system and appropriate a portion
    of the funding currently being given to chimpanzee laboratories to the
    sanctuary system. A transfer of the chimpanzees to sanctuary would: (1)
    consolidate and lessen chimpanzee maintenance costs, (2) provide the
    chimpanzees with better care, and (3) offer the public the humane
    solution they are asking for.
                             background and history
        Beginning in 1995, the National Research Council (NRC) confirmed a
    chimpanzee surplus and recommended a moratorium on breeding of
    federally owned or supported chimpanzees \1\, who now number
    approximately 500 of the more than 1,000 total chimpanzees available
    for research in the United States. On May 22, 2007, the NCRR of NIH
    announced a permanent end to the funding of chimpanzee breeding, which
    applies to all federally owned and supported chimpanzees as well as
    NIH-funded research. Further, it has also been noted that ``a huge
    number'' of chimpanzees are not being used in active research protocols
    and are therefore ``just sitting there.'' \2\ If no breeding is
    allowed, it is projected that the Government will have almost no
    financial responsibility for the chimpanzees it owns within 30 years
    due to the age of the population--any breeding today will extend this
    financial burden to 90 years.
    ---------------------------------------------------------------------------
        \2\ Cohen, J. (2007) Biomedical Research: The Endangered Lab Chimp.
    Science. 315:450-452.
    ---------------------------------------------------------------------------
        There is no justification for breeding of additional chimpanzees
    for research; therefore lack of Federal funding for breeding will
    ensure that no breeding of federally owned or supported chimpanzees for
    research will occur in fiscal year 2010.
               concerns regarding chimpanzee care in laboratories
        A 9-month undercover investigation by the HSUS at University of
    Louisiana at Lafayette New Iberia Research Center (NIRC)--the largest
    chimpanzee laboratory in the world--revealed some chimpanzees living in
    barren, isolated, conditions and documented more than 100 alleged
    violations of the Animal Welfare Act at the facility in regards to
    chimpanzees. The U.S. Department of Agriculture (USDA) and NIH's Office
    of Laboratory Animal Welfare (OLAW) have since launched formal
    investigations into the facility and NIRC was cited for several
    violations of the Animal Welfare Act during an initial site visit.
        Aside from the HSUS investigation, inspections conducted by the
    USDA demonstrate that basic chimpanzee housing requirements are often
    not being met. Inspection reports for two other federally funded
    chimpanzee facilities reported housing of chimpanzees in less than
    minimal space requirements, inadequate environmental enhancement, and/
    or general disrepair of facilities. These problems add further argument
    against the breeding of even more chimpanzees.
       chimpanzees have often been a poor model for human health research
        The scientific community recognizes that chimpanzees are poor
    models for HIV because chimpanzees do not develop AIDS. Similarly,
    chimpanzees do not model the course of the human hepatitis C virus yet
    they continue to be used for this research, adding to the millions of
    dollars already spent without a sign of a promising vaccine. According
    to the chimpanzee genome, some of the greatest differences between
    chimpanzees and humans relate to the immune system,\3\ calling into
    question the validity of infectious disease research using chimpanzees.
    ---------------------------------------------------------------------------
        \3\ The Chimpanzee Sequencing and Analysis Consortium/Mikes, TS, et
    al.,(1 September 2005) Initial sequence of the chimpanzee genome and
    comparison with the human genome, Nature 437, 69-87.
    ---------------------------------------------------------------------------
             ethical and public concerns about chimpanzee research
        Chimpanzee research raises serious ethical issues, particularly
    because of their extremely close similarities to humans in terms of
    intelligence and emotions. Americans are clearly concerned about these
    issues: 90 percent believe it is unacceptable to confine chimpanzees
    individually in Government-approved cages (as we documented during our
    investigation at NIRC); 71 percent believe that chimpanzees who have
    been in the laboratory for more than 10 years should be sent to
    sanctuary for retirement;\4\ and 54 percent believe that it is
    unacceptable for chimpanzees to ``undergo research which causes them to
    suffer for human benefit.'' \5\
    ---------------------------------------------------------------------------
        \4\ 2006 poll conducted by the Humane Research Council for Project
    Release & Restitution for Chimpanzees in laboratories.
        \5\ 2001 poll conducted by Zogby International for the Chimpanzee
    Collaboratory.
    ---------------------------------------------------------------------------
        We respectfully request the following bill or subcommittee report
    language:

        ``The Committee directs that no funds provided in this Act be used
    to support the breeding of chimpanzees for research, research that
    requires breeding of chimpanzees, or the transfer of ownership of
    federally owned chimpanzees to private entities, including endowments
    for their maintenance, with the exception of a transfer to an
    appropriate sanctuary that meets the national chimpanzee sanctuary
    system standards.''

        We appreciate the opportunity to share our views for the Labor,
    Health and Human Services, and Education, and Related Agencies
    Appropriations Act for fiscal year 2010. We hope the subcommittee will
    be able to accommodate this modest request that will save the
    Government a substantial sum of money, benefit chimpanzees, and allay
    some concerns of the public at large. Thank you for your consideration.
                                     ______

      Prepared Statement of the Harlem United Community AIDS Center, Inc.
                            funding request overview
        Harlem United Community AIDS Center, Inc. (Harlem United)
    appreciates the opportunity to submit written comments for the record
    regarding fiscal year 2010 funding for HIV/AIDS related programs.
    Harlem United was founded in 1988 as a community-based, nonprofit
    organization providing comprehensive, integrated care in a healthy and
    healing environment. We serve individuals and families living with HIV
    and AIDS in the greater Harlem and South Bronx neighborhoods of New
    York City. Touching the lives of more than 6,000 people each year
    through our programs, Harlem United offers its clients an array of
    evidence-based, outcomes-driven, culturally sensitive medical and
    support services, including: primary healthcare and dental care; mental
    health and substance use counseling; individual psychotherapy and case
    management; and supportive housing.
        For far too long, Federal funding for domestic HIV/AIDS programs
    has been inadequate, leaving communities struggling to meet the
    prevention, care, and treatment needs of people at risk for and living
    with HIV/AIDS. Harlem United values working with policymakers at the
    local, State, and Federal levels to advance policies and programs that
    support HIV prevention, care, and treatment. We respectfully request
    the subcommittee provide the following allocations in fiscal year 2010
    to promote HIV prevention and HIV related research and treatment
    innovations:
      --$1.57 billion for HIV prevention and surveillance at the Centers
            for Disease Control and Prevention (CDC) to help stem the tide
            of the Nation's HIV/AIDS epidemic, particularly among
            individuals and communities of color.
      --At least $2.81 billion in overall funding for the Ryan White
            Program, including the AIDS Drug Assistance Program, to provide
            essential services for more than 530,000 uninsured and
            underinsured low-income individuals and families impacted by
            HIV/AIDS.
      --A minimum of $610 million for the Minority AIDS Initiative, which
            funds programs across 8 Federal agencies to address HIV
            infection-related disparities among racial and ethnic groups.
      --At least $34 billion for the National Institutes of Health (NIH),
            with $3.35 billion allocated to HIV/AIDS research to help
            identify and deliver new therapies.
                           introduction and overview
        Despite ongoing prevention efforts, approximately 56,300 new HIV
    infections occur each year, and an estimated 21 percent of infected
    individuals are unaware of their HIV status. Moreover, CDC estimates
    that there are 430,000 people with HIV in the United States, who are
    not currently receiving HIV-related medical care. In 2004, the
    Institute of Medicine estimated that more than 50 percent of Americans
    living with HIV had no reliable access to the care they needed to stay
    alive. Evidence has shown that new infections have been driven in large
    part by (1) people who were unaware of their status and unwittingly
    transmitted the virus, and (2) individuals who were diagnosed, but who
    were not treatment eligible and who were engaging in risk behaviors.\1\
    Prevention programs, routine HIV testing and universal access to care
    are essential to stemming the tide of the HIV/AIDS epidemic nationwide.
    ---------------------------------------------------------------------------
        \1\ Federal guidelines do not allow for treatment until an
    individual's viral load reaches 350 or lower.
    ---------------------------------------------------------------------------
        To prevent the incidence of HIV and ensure that all people living
    with HIV/AIDS have access to comprehensive and quality care that they
    need and deserve, Harlem United advocates ongoing and significant
    Federal funding for domestic HIV/AIDS programs.
              bolster cdc hiv prevention and surveillance efforts
        The CDC estimates that there are more than 1.1 million people
    living with HIV/AIDS in the United States and an estimated 56,300 new
    infections occur each year. With these staggering statistics, it
    becomes clear that a sustained Federal investment in and commitment to
    HIV/AIDS initiatives are essential to advancing efforts to prevent and
    treat HIV infections. However, over the past 6 years, as the number of
    people living with HIV/AIDS has increased, Federal funding for HIV
    prevention programs at CDC has decreased by 19.3 percent. In fiscal
    year 2009, CDC HIV related prevention and surveillance programs were
    flat-funded after facing a $3.5 million cut in fiscal year 2008. Harlem
    United calls upon the subcommittee to provide a specific allocation of
    $1.57 billion, an increase of $877 million, for HIV prevention efforts
    at CDC.
        The current body of knowledge and research surrounding HIV
    prevention provides evidence for effective interventions, yet CDC and
    State and local public health departments do not always have the
    resources to implement them. With increased Federal funding, gaps in
    resources and fiscal needs will be alleviated and prevention efforts
    can be scaled up. Specifically, additional funding will allow CDC to
    expand HIV testing efforts and prevention outreach, particularly among
    high-risk populations and communities of color, where the epidemic is
    disproportionately concentrated. CDC also would be able to assist State
    and local health departments fund prevention programs that go beyond
    just testing for HIV. Furthermore, additional funding would allow CDC
    to continue to build the capacity of community-based organizations to
    implement evidenced-based interventions and provide technical
    assistance, Lastly, CDC would also be able to improve HIV monitoring
    and surveillance activities to ensure that accurate data on the disease
    is captured.
    preserve access to hiv treatment for low-income individuals through the
                               ryan white program
        Each year, the Ryan White Program provides care and treatment to
    more than half a million low-income individuals living with HIV/AIDS.
    This program is vital to those who have no medical coverage or face
    coverage limits, as it steps in as the ``payer of last resort.'' While
    the Ryan White Program was initially implemented as an emergency
    measure, it has become an integral part of the Nation's response to
    HIV, providing treatment for individuals who would otherwise not have
    access to care.
        The AIDS Drug Assistance Program (ADAP), a critical component of
    the Ryan White Program that exists under part B, provides HIV
    medications to program participants and funds for purchasing health
    insurance for eligible participants and services that enhance drug
    treatment therapies.
        Unfortunately, growing caseloads and costs of treatment have left
    current funding levels inadequate. As such, Harlem United calls upon
    the subcommittee to allocate at least $2.81 billion in overall funding
    for the Ryan White Program, including the AIDS Drug Assistance Program.
                    strengthen the minority aids initiative
        The HIV/AIDS epidemic in the United States has hit racial and
    ethnic minority communities hard. While only 12 percent of the U.S.
    population is African American, this racial group accounts for 49
    percent of all new AIDS cases. Hispanics account for 19 percent of new
    AIDS diagnoses, yet comprise only 12 percent of the total U.S.
    population. Combined, minorities represent 71 percent of new AIDS
    cases, 67 percent of all people living with HIV/AIDS, and 70 percent of
    deaths caused by AIDS. These grim statistics demonstrate the critical
    need for the Minority AIDS Initiative (MAI).
        MAI provides funding to community-based organizations and
    healthcare providers to implement prevention and treatment programs
    specifically tailored to racial and ethnic minority populations. The
    Initiative, designed to complement other HIV efforts, strengthens the
    capacity of organizations serving communities of color to implement
    culturally appropriate HIV prevention programs and treatment services,
    in order to reduce the incidence of HIV and improve HIV related health
    outcomes among these communities.
        Given the urgent need to reduce HIV/AIDS disparities among racial
    and ethnic communities in the United States, Harlem United urges the
    subcommittee to allocate a minimum of $610 million for the Minority
    AIDS Initiative.
                enhance hiv treatment and therapeutics research
        Despite breakthroughs in HIV treatment and prevention research,
    currently, no vaccine or cure exists for HIV/AIDS. With approximately
    56,300 new HIV cases each year, it is crucial that the United States
    increase its commitment to research aimed at the prevention and
    treatment of this disease.
        The NIH is the global leader in AIDS research. It conducts research
    on drug therapies, vaccines, and evidenced-based behavior and
    biomedical prevention interventions. Previous breakthroughs in NIH AIDS
    research include advances in antiretroviral therapy and drug regimens
    that have decreased HIV-related morbidity and mortality and reduced the
    risk of mother-to-child transmission of HIV. While NIH research has
    significantly contributed to HIV prevention and treatment programs that
    have improved the quality-of-life for many, additional and on-going
    research is needed to advance existing HIV/AIDS treatments. Therefore,
    Harlem United calls upon the subcommittee to allocate at least $34
    billion for NIH, with $3.35 billion allocated to HIV/AIDS research.
                                   conclusion
        Harlem United maintains a strong commitment to working with Members
    of Congress, other community-based organizations, and stakeholders to
    curtail the HIV epidemic and ensure that individuals living with HIV/
    AIDS have access to quality care and treatment. By providing the fiscal
    year 2010 funding levels detailed above, we believe the subcommittee
    will be taking the necessary steps towards accomplishing the goals of
    HIV prevention and universal access to care, ensuring that this disease
    will no longer threaten our Nation.
                                     ______

               Letter From The Interstitial Cystitis Association
                                                          May 22, 2009.
    Hon. Tom Harkin,
    Chairman, Subcommittee on Labor, Health and Human Services, and
            Education, and Related Agencies, Washington, DC.
    Hon. Thad Cochran,
    Ranking Member, Subcommittee on Labor, Health and Human Services, and
            Education, and Related Agencies, Washington, DC.
        Dear Senator Harkin and Cochran: Thank you very much for your
    continued leadership in advancing healthcare policy.
        Interstitial cystitis (IC) is pelvic pain, pressure, or discomfort
    related to the bladder typically associated with high urinary frequency
    and urgency, in the absence of infection or other pathology. IC is also
    called chronic pelvic pain syndrome, painful bladder syndrome (PBS),
    and bladder pain syndrome (BPS).
        The Interstitial Cystitis Association (ICA) is a nonprofit
    organization committed to finding more effective treatments and a cure
    for interstitial cystitis. ICA promotes IC research; educates the
    medical community and public; advocates for IC patients, healthcare
    providers and researchers; and offers support for IC patients and their
    families. In this capacity the ICA requests the following funding
    considerations for the fiscal year 2010 Labor, Health and Human
    Services, and Education, and Related Agencies bill:
      --A 7 percent increase for the National Institutes of Health (NIH)
            for fiscal year 2010. A 7 percent increase will allow NIH to
            continue to expand basic biomedical research on all diseases,
            and take advantage of the explosion of opportunities that exist
            in reducing suffering from debilitating medical disorders.
      --A 7 percent increase for the National Institute of Diabetes and
            Digestive and Kidney Diseases (NIDDK). NIDDK is the key NIH
            agency funding research on interstitial cystitis (IC). ICA
            urges that NIDDK continue to expand the research portfolio on
            IC, so millions of American women and men can benefit from
            advances and breakthroughs in medical care and treatments.
            NIDDK supports the Multidisciplinary Approach to Chronic Pelvic
            Pain clinical trial-a critical priority of ICA.
      --A 7 percent increase for the NIH Office of Research on Women's
            Health. Located in the NIH Office of the Director, the NIH
            Office of Women's Health supports research and program
            activities that contribute to the understanding of interstitial
            cystitis which primarily affects women.
      --$1 million for the Centers for Disease Control and Prevention (CDC)
            interstitial cystitis program. A funding level of $1 million
            will allow the modest expansion of IC program activities at CDC
            and continue the critical CDC/ICA cooperative agreement on
            public and professional awareness on interstitial cystitis.
        Thank you for the opportunity to present the views of the IC
    community. Please do not hesitate to contact me if there is any more
    information you would like us to provide for your consideration.
                Sincerely,
                                                Barbara Gordon,
                                                    Executive Director.
                                     ______

        Prepared Statement of the Infectious Diseases Society of America
        The Infectious Diseases Society of America (IDSA) appreciates this
    opportunity to speak in support of Federal efforts to prevent, detect,
    and respond to infectious diseases in the United States and abroad as
    part of the fiscal year 2010 funding cycle. IDSA represents more than
    8,500 infectious diseases physicians and scientists devoted to patient
    care, prevention, public health, education, and research. Our members
    care for patients of all ages with serious infections, including
    meningitis, pneumonia, tuberculosis (TB), antibiotic-resistant
    bacterial infections such as methicillin-resistant Staphylococcus
    aureus (MRSA), and those with cancer or transplants who have life-
    threatening infections caused by unusual microorganisms, food
    poisoning, and HIV/AIDS, as well as emerging infections like the 2009
    H1N1 virus (swine influenza) and severe acute respiratory syndrome
    (SARS).
    2009 H1N1 Virus (Swine Influenza)
        IDSA's leadership strongly commends the administration's efforts to
    date in managing and responding to the 2009 H1N1 outbreak. Of critical
    importance, experts and scientists are driving key decisions. The
    leadership of the Centers for Disease Control and Prevention (CDC) and
    the Department of Health and Human Services (HHS) has been strong, and
    their coordination with other Federal, State, and local governments is
    clear. Undeniably, the investments and subsequent preparations the
    country has made since the National Strategy for Pandemic Influenza was
    issued in November 2005 are paying off. As the 2009 H1N1 virus outbreak
    unfolds, we are witnessing firsthand the important role a robust public
    health infrastructure plays in rapidly detecting and containing disease
    outbreaks. Yet, additional resources are needed to adequately respond
    to the 2009 H1N1 outbreak as well as to continue to prepare our Nation
    for other bioemergencies.
        We thank the subcommittee for providing funding for pandemic
    influenza preparedness and response activities in the recent fiscal
    year 2009 supplemental bill. IDSA supports a funding level of $2.05
    billion to complete the funding to implement the National Strategy for
    Pandemic Influenza, as well as to develop a 2009 H1N1 virus vaccine and
    replenish the Strategic National Stockpile, support grants to State and
    local health departments so they may adequately prepare for and respond
    to the 2009 H1N1 virus and other infectious diseases outbreaks, and
    provide additional funding for global pandemic preparedness activities.
    IDSA further believes that funding is needed annually to adequately
    maintain State and local pandemic preparedness activities. IDSA also
    strongly supports strengthening funding for ongoing pandemic influenza
    preparedness activities at CDC, the Food and Drug Administration (FDA),
    National Institutes of Health (NIH), and HHS' Office of the Secretary.
        Congress also must fully fund the Biomedical Advanced Research and
    Development Authority (BARDA) within HHS so that the United States can
    begin to realize goals envisioned under the Pandemic and All-Hazards
    Act enacted in 2006 to address a broad spectrum of biological threats
    in addition to pandemic influenza. IDSA recommends that $1.7 billion of
    multi-year appropriations be allocated to BARDA in fiscal year 2010 to
    fund biological therapeutics, diagnostics, vaccines, and other
    technologies. Such funding would help ensure the availability of
    resources throughout the stages of development and the flexibility for
    BARDA to partner effectively with industry.
    CDC
        A strong CDC is essential to the United States' efforts to rapidly
    detect and control infectious diseases as witnessed by the current H1N1
    outbreak. CDC is the primary Federal agency responsible for conducting
    and supporting public health protection through health promotion,
    prevention, preparedness, and research. IDSA recommends increasing
    funding for CDC's core programs to $8.6 billion, to enable it to
    maintain a strong public health infrastructure and protect Americans
    from public health threats and emergencies.
        IDSA is especially concerned about CDC's Infectious Diseases
    program budget, which supports critical management and coordination
    functions for infectious diseases science, program, and policy,
    including related specific epidemiology and laboratory activities. IDSA
    recommends an fiscal year 2010 funding level of $2.7 billion for CDC's
    Infectious Diseases programs.
        Within the Infectious Disease programs' proposed budget, the
    agency's already severely strapped Antimicrobial Resistance budget
    stands at $16.9 million. This vital program is necessary to help combat
    the rising tide of drug resistance, a critical medical problem marked
    most publicly by the upsurge in methicillin-resistant Staphylococcus
    aureus (MRSA) and other drug-resistant bacterial infections.
    Antimicrobial resistance also has serious implications for our
    collective response to the 2009 H1N1 virus. Viruses are unpredictable,
    and should the 2009 H1N1 virus develop resistance to oseltamivir and
    zamamir, our ability to respond effectively to the influenza outbreak
    will significantly diminish. For these reasons, IDSA recommends
    increasing fiscal year 2010 funding for resistance programs at CDC by
    $48 million, to a total of $65 million. Such funding increases will
    enable CDC to more effectively gather morbidity and mortality data
    related to resistance, track the development of dangerous resistant
    bugs as they develop, educate physicians, patients and the public about
    the need to protect the long-term effectiveness of antimicrobial drugs,
    and strengthen infection control activities across the United States.
    This recommended level coincides well with an internal CDC professional
    judgment prepared last year which, unfortunately, was not provided to
    Congress.
        The Emerging Infectious Diseases (EI) budget line boosts the
    agency's capacity to nimbly identify and respond to emerging
    infections, such as the 2009 H1N1 virus. Much of CDC's infectious
    diseases funding is highly disease-targeted, making it difficult to
    fund cross-cutting or emergent needs. Unique in its flexibility, the EI
    line supports dozens of research and surveillance programs that address
    new and unpredictable threats. Such threats have included rabies,
    rotavirus, food-borne diseases, Ebola and SARS. Inadequate funding
    would severely affect CDC's laboratory capacity, research grants to
    academic partners, and support for State public health departments and
    public health laboratories and would reduce CDC's flexibility in
    setting priorities and taking action against new infections that may
    emerge throughout the year. IDSA recommends, at a minimum, that the
    Other Emerging Infectious Diseases line item be increased to $160
    million for fiscal year 2010.
        Immunizing our population against vaccine--preventable diseases is
    one of our country's greatest public health achievements. Through CDC's
    Section 317 Program, which funds State and local immunizations efforts,
    the United States has made significant progress toward eliminating
    vaccine-preventable diseases among children. IDSA applauds the actions
    by the Congress over the past year to increase funding for this program
    in the American Recovery and Reinvestment Act and in the fiscal year
    2009 omnibus appropriations bill. At a time when new CDC-recommended
    vaccines are available and a greater commitment to immunizations for
    both children and adults is necessary, we need to continue to increase
    access to this critical intervention that saves lives and millions of
    dollars in unnecessary medical spending. To build on this important
    effort, IDSA recommends a funding level for the Section 317 Program of
    $802 million in fiscal year 2010.
        IDSA also supports changes which will significantly strengthen the
    Section 317 Program's support for adult and adolescent immunization.
    Each year, more than 46,000 adults die of vaccine-preventable diseases.
    Costs related to illnesses from adult vaccine-preventable diseases are
    approximately $10 billion. IDSA recommends the establishment of
    distinct funding floors for adult vaccine purchase and infrastructure
    in amounts sufficient to cover immunization of the majority of under-
    insured and uninsured adults with all CDC-recommended vaccines.
        Last year, Congress passed landmark legislation in the
    Comprehensive Tuberculosis Elimination Act of 2008. This bill
    authorizes a number of actions that will shore up State TB control
    programs, enhance U.S. capacity to deal with the serious threat of
    drug-resistant tuberculosis, and escalate our efforts to develop
    urgently needed ``tools,'' such as drugs, diagnostics, and vaccines.
    Realizing these goals will require additional resources. At a minimum,
    it is critical that the funding authorized for fiscal year 2010 in this
    important law--$210 million--be appropriated for the CDC Division of TB
    Elimination. The bill also separately authorized $100 million for
    development of TB diagnostics, treatments and prevention tools, which
    IDSA also supports for inclusion in fiscal year 2010 appropriations.
        HIV prevention and surveillance activities at CDC are critical to
    reducing the number of new cases occurring annually in the United
    States. Sufficient resources must be devoted to HIV prevention to
    support CDC's portfolio of prevention programs, including the
    initiative to identify people with HIV/AIDS earlier through routine HIV
    screening. This program will lead to lifesaving care sooner and will
    help to prevent further transmissions. IDSA supports funding in the
    amount of $1.57 billion for these programs in fiscal year 2010. We also
    support funding of $2.81 billion for the Ryan White CARE Act programs
    within the Health Resources and Services Administration and urge you to
    increase funding for critical part C medical care by $68.4 million, to
    a total of $270.3 million for part C programs. Ryan White programs
    provide a vital link in our healthcare safety net and are currently
    struggling to meet the need for HIV services in communities across the
    country.
    NIH
        NIH is the single-largest funding source for infectious diseases
    research in the United States and the life-source for many academic
    research centers. The NIH-funded work conducted at these centers lays
    the groundwork for advancements in treatments, cures, and other medical
    technologies. Between 2003 and 2009, NIH lost 13 percent of its
    purchasing power due to the rate of biomedical research inflation and
    stagnating annual budgets. Because of the flat budget, 3 out of 4
    research proposals submitted to NIH were not funded. Peer reviewers
    were forced to become more risk averse, leading to a narrowing of
    scientific vision and a diminishing rate of medical advancement.
    Without medical advancements, thousands of Americans will have to wait
    longer for the cures they need.
        IDSA is extremely pleased that the recently enacted American
    Recovery and Reinvestment Act provided $10 billion in additional
    funding to support NIH's research efforts in 2009 and 2010. Congress
    rightfully acknowledged the role of scientific research in stimulating
    the economy. It is vital, however, that this long overdue increase in
    funding be sustained and become part of NIH's baseline. Making this
    increase permanent ultimately will translate into long-term
    improvements in human health, both domestically and globally.
        NIH's Fogarty International Center is at the forefront of global
    health and is a leader in extending the U.S. Federal biomedical
    enterprise abroad. It taps innovative thinking from all parts of the
    world and fosters important scientific partnerships. Through Fogarty,
    the United States has supported research and research training programs
    conducted by both U.S. and foreign investigators across a wide range of
    infectious diseases and needs, including HIV/AIDS, malaria, and
    tuberculosis. The Center's efforts have led to improved local health
    outcomes--but so much more can be done. For this reason, IDSA strongly
    supports increasing Fogarty's funding level in fiscal year 2010 to $100
    million--an increase of $31.3 million. These additional resources will
    enable Fogarty to increase research training initiatives, forge new
    partnerships between U.S. and foreign research institutions, and
    conduct much-needed implementation research to increase the
    effectiveness of international programs.
        IDSA also urges the National Institute of Allergies and Infectious
    Diseases (NIAID) at NIH to increase its antimicrobial resistance
    research funding by $100 million in fiscal year 2010, bringing overall
    funding in this area to $271 million. This will allow NIAID to
    strengthen clinical research and establish a clinical trials network to
    study resistant infections as well as antibacterial use and
    development. Well-designed, multi-center, randomized, controlled trials
    would create an excellent basis of evidence from which coherent and
    defensible recommendations could be developed.
    FDA
        Additionally, in the Agriculture Appropriations bill, IDSA supports
    a strengthening of antimicrobial resistance efforts at FDA.
    Specifically we support a $20 million increase in antimicrobial
    resistance funding for FDA in fiscal year 2010, bringing the agency's
    resistance funding to $44 million. This will allow FDA to establish and
    periodically update antibiotic susceptibility breakpoints based on
    testing and data collection, including through the purchase of vendor
    data; fund Critical Path initiatives for antibiotics; more aggressively
    review the safety of antibiotic use in food animals; and quicken its
    pace in developing critical guidance for industry on antibiotic
    clinical trial designs.
        Today's investment in infectious diseases research, prevention, and
    treatments will pay significant dividends in the future by dramatically
    reducing healthcare costs and improving the quality of life of millions
    of Americans and others. It also will continue to enable Federal
    agencies to respond effectively and efficiently to the 2009 H1N1 virus
    and other potentially devastating outbreaks.
                                     ______

       Prepared Statement of the International Foundation for Functional
                           Gastrointestinal Disorders
                summary of recommendations for fiscal year 2010
        Provide a funding increase of at least 7 percent for the National
    Institutes of Health (NIH) and its Institutes and Centers.
        Urge the National Institute of Diabetes and Digestive and Kidney
    Diseases (NIDDK) to prioritize and implement the recently released
    research recommendations of the National Commission on Digestive
    Diseases.
        Urge NIH And NIDDK to expand the research portfolio on functional
    gastrointestinal and motility disorders, such as Irritable Bowel
    Syndrome (IBS).
        Thank you for the opportunity to present this written statement
    regarding the importance of functional gastrointestinal and motility
    disorders research.
        Since our establishment in 1991, the International Foundation for
    Functional Gastrointestinal Disorders (IFFGD) has been dedicated to
    increasing awareness of functional gastrointestinal and motility
    disorders among the public, health professionals, and researchers. We
    also work to bolster digestive disease research and generate new
    treatment option for patients. For example, IFFGD worked with the
    NIDDK, the National Institute of Child Health and Human Development
    (NICHD), and the Office of Medical Applications of Research (OMAR) to
    facilitate an NIH State-of-the-Science Conference on the Prevention of
    Fecal and Urinary Incontinence in Adults, which was held in December of
    2007. Furthermore, I served on the National Commission on Digestive
    Diseases (NCDD) which recently released a long-range road map for
    digestive disease research, entitled Opportunities and Challenges in
    Digestive Diseases Research: Recommendations of the National Commission
    on Digestive Diseases
        The majority of diseases and disorders we address have no cure and
    treatment options are often limited. We have yet to completely
    understand the mechanisms of the underlying conditions. Patients face a
    life of learning to manage a chronic illness that is accompanied by
    pain and an unrelenting myriad of gastrointestinal symptoms. The
    medical and indirect costs associated with these diseases are enormous;
    estimates range from $25 billion-$30 billion annually. Economic costs
    spill over into the workplace, and are reflected in work absenteeism
    and lost productivity. Furthermore, the human toll is not only on the
    individual but also on the family. In essence, these diseases account
    for lost opportunities for the individual and society.
                                      ibs
        IBS strikes people from all walks of life. It affects 30 million to
    45 million Americans and results in significant human suffering and
    disability. This chronic disease is characterized by a group of
    symptoms, which include abdominal pain or discomfort associated with a
    change in bowel pattern, such as diarrhea and/or constipation. Although
    the cause of IBS is unknown, we do know that this disease needs a
    multidisciplinary approach in research and treatment.
        IBS can be emotionally and physically debilitating. Due to
    persistent pain and bowel unpredictability, individuals who suffer from
    this disorder may distance themselves from social events, work, and
    even may fear leaving their home.
        Numerous research recommendations regarding IBS were included as
    components of the NCDD's Long-Range Research Plan for Digestive
    Diseases. For fiscal year 2010, IFFGD urges Congress to review the
    NCDD's Report, and provide NIH and NIDDK with the resources necessary
    to adequately implement the plan's recommendations.
                               fecal incontinence
        At least 12 million Americans suffer from fecal incontinence.
    Incontinence is neither part of the aging process nor is it something
    that affects only the elderly. Incontinence crosses all age groups from
    children to older adults, but is more common among women and in the
    elderly of both sexes. Often it is a symptom associated with various
    neurological diseases and many cancer treatments. Yet, as a society, we
    rarely hear or talk about the bowel disorders associated with spinal
    cord injuries, multiple sclerosis, diabetes, prostate cancer, colon
    cancer, uterine cancer, and a host of other diseases.
        Damage to the anal sphincter muscles; damage to the nerves of the
    anal sphincter muscles or the rectum; loss of storage capacity in the
    rectum; diarrhea; or pelvic floor dysfunction can cause fecal
    incontinence. People who have fecal incontinence may feel ashamed,
    embarrassed, or humiliated. Some don't want to leave the house out of
    fear they might have an accident in public. Most attempt to hide the
    problem for as long as possible. They withdraw from friends and family,
    and often limit work or education efforts. Incontinence in the elderly
    burdens families and is the primary reason for nursing home admissions,
    an already huge social and economic burden in our increasingly aged
    population.
        In November 2002, IFFGD sponsored a consensus conference entitled,
    Advancing the Treatment of Fecal and Urinary Incontinence Through
    Research: Trial Design, Outcome Measures, and Research Priorities.
    Among other outcomes, the conference resulted in six key research
    recommendations including more comprehensive identification of quality
    of life issues; improved diagnostic tests for affecting management
    strategies and treatment outcomes; development of new drug treatment
    compounds; development of strategies for primary prevention of fecal
    incontinence associated with childbirth; and attention to the process
    of stigmatization as it applies to the experience of individuals with
    fecal incontinence.
        In December 2007, IFFGD collaborated with NIDDK, NICHD, and OMAR on
    the NIH State-of-the-Science Conference on the Prevention of Fecal and
    Urinary Incontinence in Adults. The goal of this conference was to
    assess the state-of-the-science and outline future priorities for
    research on both fecal and urinary incontinence; including, the
    prevalence and incidence of fecal and urinary incontinence, risk
    factors and potential prevention, pathophysiology, economic and quality
    of life impact, current tools available to measure symptom severity and
    burden, and the effectiveness of both short and long term treatment.
    For fiscal year 2010, IFFGD urges Congress to review the Conference's
    Report and provide NIH with the resources necessary to effectively
    implement the report's recommendations.
                     gastroesophageal reflux disease (gerd)
        Gastroesophageal reflux disease, or GERD, is a common disorder
    affecting both adults and children, which results from the back-flow of
    acidic stomach contents into the esophagus. GERD is often accompanied
    by persistent symptoms, such as chronic heartburn and regurgitation of
    acid. Sometimes there are no apparent symptoms, and the presence of
    GERD is revealed when complications become evident. One uncommon but
    serious complication is Barrett's esophagus, a potentially pre-
    cancerous condition associated with esophageal cancer. Symptoms of GERD
    vary from person to person. The majority of people with GERD have mild
    symptoms, with no visible evidence of tissue damage and little risk of
    developing complications. There are several treatment options available
    for individuals suffering from GERD. Nonetheless, treatment response
    varies from person to person, is not always effective, and long-term
    medication use and surgery expose individuals to risks of side-effects
    or complications.
        Gastroesophageal reflux (GER) affects as many as one-third of all
    full term infants born in America each year. GER results from an
    immature upper gastrointestinal motor development. The prevalence of
    GER is increased in premature infants. Many infants require medical
    therapy in order for their symptoms to be controlled. Up to 25 percent
    of older children and adolescents will have GER or GERD due to lower
    esophageal sphincter dysfunction. In this population, the natural
    history of GER is similar to that of adult patients, in whom GER tends
    to be persistent and may require long-term treatment.
                                 gastroparesis
        Gastroparesis, or delayed gastric emptying, refers to a stomach
    that empties slowly. Gastroparesis is characterized by symptoms from
    the delayed emptying of food, namely: bloating, nausea, vomiting, or
    feeling full after eating only a small amount of food. Gastroparesis
    can occur as a result of several conditions, including being present in
    30 percent to 50 percent of patients with diabetes mellitus. A person
    with diabetic gastroparesis may have episodes of high and low blood
    sugar levels due to the unpredictable emptying of food from the
    stomach, leading to diabetic complications. Other causes of
    gastroparesis include Parkinson's disease and some medications,
    especially narcotic pain medications. In many patients the cause of the
    gastroparesis cannot be found and the disorder is termed idiopathic
    gastroparesis. Over the last several years, as more is being found out
    about gastroparesis, it has become clear this condition affects many
    people and the condition can cause a wide range of symptom severity.
                            cyclic vomiting syndrome
        Cyclic vomiting syndrome (CVS) is a disorder with recurrent
    episodes of severe nausea and vomiting interspersed with symptom-free
    periods. The periods of intense, persistent nausea, vomiting, and other
    symptoms (abdominal pain, prostration, and lethargy) lasts hours to
    days. Previously thought to occur primarily in pediatric populations,
    it is increasingly understood that this crippling syndrome can occur in
    a variety of age groups including adults. Patients with these symptoms
    often go for years without correct diagnosis. The condition leads to
    significant time lost from school and from work, as well as substantial
    medical morbidity. The cause of CVS is not known. Better understanding,
    through research, of mechanisms that underlie upper gastrointestinal
    function and motility involved in sensations of nausea, vomiting and
    abdominal pain is needed to help identify at risk individuals and
    develop more effective treatment strategies.
                         support for critical research
        IFFGD urges Congress to provide the necessary funding for the
    expansion of the research activities at NIDDK and the Office of
    Research on Women's Health (ORWH) regarding functional gastrointestinal
    disorders and motility disorders. Additional funding will allow
    necessary growth of the research portfolios on functional
    gastrointestinal disorders and motility disorders at NIDDK and ORWH,
    and also facilitate implementation of the NCDD's research
    recommendations.
        Recent years of near level-funding at NIH have negatively impacted
    the mission of its Institutes and Centers. For this reason, IFFGD
    applauds initiatives like Senator Arlen Specter's (R-PA) successful
    effort to provide NIH with $10.4 billion in stimulus funds. IFFGD urges
    this subcommittee to show strong leadership in pursuing substantial
    funding increase through the regular appropriations process in fiscal
    year 2010.
        For fiscal year 2010, IFFGD recommends a funding increase of at
    least 7 percent for NIH and its Institutes and Centers.
                                     ______

           Prepared Statement of the International Myeloma Foundation
        The International Myeloma Foundation (IMF) appreciates the
    opportunity to submit written comments for the record regarding fiscal
    year 2010 funding for myeloma cancer programs. The IMF is the oldest
    and largest myeloma foundation dedicated to improving the quality of
    life of myeloma patients while working toward prevention and a cure.
        To ensure that myeloma patients have access to the comprehensive,
    quality care they need and deserve, the IMF advocates on-going and
    significant Federal funding for myeloma research and its application.
    The IMF stands ready to work with policymakers to advance policies and
    programs that work toward prevention and a cure for myeloma and for all
    other forms of cancer.
                               myeloma background
        Myeloma is a cancer in the bone marrow affecting production of red
    cells, white cells, and stem cells. It is also called ``multiple
    myeloma,'' because multiple areas of bone marrow may be involved.
    Myeloma is the second most common blood cancer after lymphomas,
    affecting an estimated 750,000 people worldwide and its prevalence
    appears to be is increasing significantly.
        No one knows the exact causes of myeloma. Doctors can seldom
    explain why one person develops this disease and another does not.
    Research has shown that people with certain risk factors such as age
    and race are more likely than others to develop myeloma. Growing older
    increases the chance of developing multiple myeloma as most people with
    myeloma are diagnosed after age 65. However, in recent years the
    diagnosis of myeloma in people 40 years of age and younger appears to
    have become more common as our ability to detect and diagnose this
    disease has improved. The risk of myeloma is highest among African
    Americans and lowest among Asian Americans.
        Scientists are studying other possible risk factors for myeloma.
    Toxic chemicals (for example, agricultural chemicals and Agent Orange
    used in Vietnam), radiation (including atomic radiation), and several
    viruses (including HIV, hepatitis, herpes virus 8, and others) are
    associated with an increased risk of myeloma and related diseases.
        According to the American Cancer Society, 19,920 Americans were
    expected to be diagnosed with myeloma and 10,690 would lose their
    battle with this disease in 2008. Even while they live with the
    disease, myeloma patients can suffer debilitating fractures and other
    bone disorders, severe side effects of their treatment, and other
    problems that profoundly affect their quality of life, and
    significantly impact the cost of their healthcare. Despite these grim
    statistics, significant gains in the battle against myeloma have been
    made through our Nation's investment in cancer research and its
    application. Research holds the key to improved myeloma prevention,
    early detection, diagnosis, and treatment, but such breakthroughs are
    meaningless unless we can deliver them to all Americans in need.
                sustain and seize cancer research opportunities
        Our Nation has benefited immensely from past Federal investment in
    biomedical research at the National Institutes of Health (NIH). The IMF
    advocates $33.3 billion for NIH in fiscal year 2010. This will allow
    NIH to sustain and build on its research progress resulting from the
    recent doubling of its budget while avoiding the severe disruption to
    that progress that would result from a minimal increase. Myeloma
    research is producing extraordinary breakthroughs--leading to new
    therapies that translate into longer survival and improved quality of
    life for myeloma patients. Although myeloma was once considered a death
    sentence with limited options for treatment, myeloma is an example of
    the progress that can be made and the work that still lies ahead in the
    war on cancer. Many myeloma patients are living proof of what
    innovative drug development and clinical research can achieve--
    sequential remissions, long-term survival and good quality of life. But
    these achievements are not a substitute for a cure and therefore the
    IMF calls upon Congress to allocate $6 billion to the National Cancer
    Institute in fiscal year 2010 to continue our battle against myeloma
    and its sequelae.
     boost our nation's investment in myeloma prevention, early detection,
                                 and awareness
        As the Nation's leading prevention agency, the Centers for Disease
    Control and Prevention (CDC) plays an important role in translating and
    delivering at the community level what is learned from research.
    Therefore, the IMF joins with our partners in the cancer community--
    including One Voice Against Cancer--in calling on Congress to provide
    additional resources for the CDC to support and expand much-needed and
    proven efforts in such areas as cancer prevention, early detection, and
    risk reduction. Specifically, the IMF advocates the appropriation of
    $471 million in fiscal year 2010 for CDC's cancer prevention and
    control initiatives.
        Within that allocation, the IMF specifically advocates $6 million
    for the Geraldine Ferraro Blood Cancer Program. Authorized under the
    Hematological Cancer Research Investment and Education Act of 2002,
    this program was created to provide public and patient education about
    blood cancers, including myeloma.
        With grants from the Geraldine Ferraro Blood Cancer Program, the
    IMF has successfully promoted awareness of myeloma, particularly in the
    African-American community and other underserved communities. IMF
    accomplishments include the production and distribution of more than
    4,500 copies of an informative video which addresses the importance of
    myeloma awareness and education in the African-American community to
    churches, community centers, inner-city hospitals, and Urban League
    offices around the country, increased African-American attendance at
    IMF Patient and Family Seminars (these seminars provide invaluable
    treatment information to newly diagnosed myeloma patients), increased
    calls by African-American myeloma patients, family members, and
    caregivers to the IMF myeloma hotline, and the establishment of
    additional support groups in inner city locations in the United States
    to assist underserved areas with myeloma education and awareness
    campaigns. Furthermore, the more than 90 IMF-affiliated patient support
    groups in the United States also made this effort their main goal
    during ``Myeloma Awareness Week'' in October 2005.
        An allocation of $6 million in fiscal year 2010 will allow this
    important program to continue to provide patients--including those
    populations at highest risk of developing myeloma--with educational,
    disease management and survivorship resources to enhance treatment and
    prognosis.
                                   conclusion
        The IMF stands ready to work with policymakers to advance policies
    and support programs that work toward prevention and a cure for
    myeloma. Thank you for this opportunity to discuss the fiscal year 2010
    funding levels necessary to ensure that our Nation continues to make
    gains in the fight against myeloma.
                                     ______

              Prepared Statement of the Jeffrey Modell Foundation
        Thank you for the opportunity to present to you our testimony
    concerning the activities of the Jeffrey Modell Foundation (JMF)
    dedicated to Primary Immunodeficiency (PI). As you know, most of our
    programs are conducted in partnership with various governmental
    agencies under the jurisdiction of this subcommittee. We very much
    appreciate the support, generosity, and kindness of spirit that we have
    received from the members and staff of this subcommittee and look
    forward to continuing to work together closely in the future.
        As a baseline, Mr. Chairman, please let me make clear the following
    four fundamental points:
      --JMF programs always include our own investment of funds and
            resources, thereby assuring accountability.
      --JMF programs improve patients' quality of life issues through
            prevention and earliest possible diagnosis.
      --JMF programs, therefore, lower healthcare costs.
      --JMF programs save lives as demonstrated in the 2008 Wisconsin
            newborn screening program.
        All of the data concerning the impact of the education and
    awareness program that this subcommittee has long supported has been
    published in a leading scientific journal, ``Immunologic Research'',
    Humana Press, January 13, 2009 and is entitled, ``From Genotype to
    Phenotype. Further Studies Measuring the Impact of a Physician
    Education and Public Awareness Campaign on Early Diagnosis and
    Management of Primary Immunodeficiencies''.
         physician education and public awareness campaign on primary
                               immunodeficiencies
        Five years ago, Mr. Chairman, this subcommittee set us on a path to
    work with the Centers for Disease Control and Prevention (CDC) to
    create a physician education and public awareness program. Today, that
    program has far exceeded even our most optimistic dreams.
        JMF has now generated more than $100 million in donated media from
    television, radio, print, Web site, airport, and mall dioramas. This
    translates to more than $18 million annually and represents $7 donated
    to support this campaign for every $1 of Government support
    appropriated by this subcommittee. But all that visibility would be
    meaningless if there were not real impact on the health of these
    patients. And, there are.
        The number of patients referred, tested, diagnosed, and treated has
    more than doubled every year for the past 5 years in which the campaign
    has been conducted.
        The Jeffrey Modell Centers Network of Research, Diagnostic and
    Referral Centers now include 304 physicians, from 138 academic teaching
    hospitals and medical schools. Twenty-three of the 30 ``Best Pediatric
    Hospitals'' in the United States are designated Jeffrey Modell Centers.
    The physician-experts at these centers have provided JMF with data on
    more then 30,000 patients. And we can now pinpoint the specific
    disease, where the patient is treated, who is treating the patient, and
    how the patient is treated. This data can make an enormous contribution
    to registries not only in the United States, but on a global platform.
        After diagnosis and treatment, physicians reported annual decreases
    of more than 70 percent in the number of severe infections, physician,
    hospital, and emergency room visits, pneumonias, school/work days
    missed, days in hospital, acute infections, and days with chronic
    infections.
        The consequences of these changes in patient outcomes were assigned
    economic values. JMF's published study drew from the hospital
    accounting reports at the Centers for Medicare and Medicaid services.
    The specific hospital charges and length of stay data was obtained from
    the Hospital Cost and Utilization Project, Nationwide In-patient
    Sample, under the auspices of the Agency for Healthcare Research and
    Quality.
        The study showed that each undiagnosed patient costs the healthcare
    system $102,736 annually in emergency room visits, hospitalizations,
    and medical treatment for severe complications. It costs $22,696
    annually to treat patients after they have been diagnosed-a savings of
    more than $80,000 per patient per year.
        The National Institutes of Helath (NIH) states that ``while
    individual primary immunodeficiency diseases are somewhat rare,
    affecting 500,000 Americans, this group of diseases may affect 1-2
    percent of the U.S. population or 3 million-6 million Americans.''
    Using the most conservative estimate, the minimum cost to the U.S.
    healthcare system for undiagnosed PI patients is more than $40 billion
    annually. Ensuring that these patients are properly diagnosed makes
    enormous economic sense, not to mention their improved quality of life.
                        research collaboration with nih
        JMF established a $12 million research partnership with four of the
    U.S. National Institutes of Health. The RO1 research grants solicit
    investigations on Primary Immunodeficiency (PI) diseases. JMF also
    established the Robert A. Good/Jeffrey Modell International Fellowship
    Program, funding the brightest young investigators from around the
    world, focused on PI and stem cell transplantation. JMF awarded 4
    Fellowships in 2008 under this program.
        Finally, in 2008, JMF established Endowed Chairs in Pediatric
    Immunology Research at Children's Hospital Boston, Children's Hospital
    Seattle, as well as the Jeffrey Modell Endowed Fellowship in Immunology
    Research at the University of Washington.
                newborn screening for primary immunodeficiencies
        JMF and the State of Wisconsin launched the first newborn screening
    program for Severe Combined Immune Deficiency. Since January 2008,
    every baby born in the State of Wisconsin has been screened. The T Cell
    Receptor Excision Circles assay was utilized and the screening test
    identified a patient with a combined immunodeficiency disease. The baby
    received a life-saving bone marrow transplant. The screening protocol
    has picked up several other newborns with life threatening disorders
    including Complete Di George Syndrome, T-Cell lymphopenia, and a
    disorder where white blood cells are unable to migrate to sites of
    infection. We anticipate that Massachusetts, Illinois, Connecticut,
    Texas, and New York will move forward with pilot programs in 2009.
        At this date, the cost to screen for these life threatening
    diseases is $5 per child. It is anticipated that this cost will
    decrease. There are approximately 4 million newborns per year in the
    United States. Thus, the outside cost to screen every newborn in the
    United States is estimated to be less than $20 million.
    spirit--software for primary immunodeficiency recognition intervention
                                  and tracking
        JMF brought its 2008 data to the annual meeting of the Managed Care
    Network (MCN). Senior executives and medical directors of private and
    Medicare/Medicaid health plans nationwide, as well as the leadership of
    pharmacy groups representing more than 150 million covered lives,
    attended the 2-day meeting. JMF was asked to develop an early warning
    system software program matching the ICD-9 codes to the 10 Warning
    Signs and Physician Algorithm. This software, known as SPIRIT, is now
    in development and will be piloted with National managed care carriers
    during 2009. The software protocol is being developed by JMF and its
    Medical Advisory Board, and the technology will be produced by Xcenda,
    a division of AmeriSource Bergen Corporation. Besides the listing of
    the ICD-9 codes, the program assigns relative weights for each code,
    identifies each code as a chronic or acute condition, and provides
    specific exclusion criteria.
                                    summary
        Mr. Chairman, I hope you will agree that the many programs run by
    the Jeffrey Modell Foundation are a ``perfect fit'' with the announced
    approach to reforming healthcare articulated by the President and
    currently being addressed by this Congress. Specifically we have
    focused our attention on:
      --Prevention through physician education and public awareness;
      --Quality of care through the JMF Network of specialized centers;
      --Control of healthcare costs through early diagnosis and Newborn
            Screening; and
      --Use of technology to streamline records and generate electronic
            data though new software developed by JMF for third-party
            payers.
        For fiscal year 2010, we bring you what we consider to be a very
    modest agenda:
      --We ask for no new appropriations or programs from the subcommittee.
      --We ask for continuation of the successful programs that we are now
            operating.
      --We ask for Government encouragement and support for these programs.
        In exchange, we can assure you that we will continue to contribute
    our own funds to every program with which we are involved. We will
    continue to operate these programs by fully exercising good management
    and ever-cognizant of our responsibilities to this subcommittee and to
    the taxpayers who have supplied the funds that you pass on to us.
        Mr. Chairman, we are at a critical time in our Nation's healthcare
    history. JMF is proud of the contributions we have made to the
    healthcare system and look forward to continuing to work with you and
    with all members of Congress to continue to serve the American people.
                                     ______

               Prepared Statement of the Mentor Consulting Group
              ``It must not for a moment be forgotten that the core of any
            social plan must be the child.''
                                                    President Franklin
                                                    Roosevelt
                                                    U.S. Committee on
                                                    Economic Security,
                                                    Report to the
                                                    President, 1935

        Senator Harkin and distinguished members of the subcommittee:
    Mentor Consulting Group (MCG) is pleased to submit testimony for the
    outside witness record to ask the subcommittee to direct its attention
    to the President's fiscal year 2010 proposed budget recommendation
    calling for the elimination of the U.S. Department of Education's (ED)
    mentoring program. MCG is seeking your help in restoring the funding
    for this important and much needed program to enable agencies from
    Storm Lake, Iowa, to McAllen, Texas, from Rhinelander, Wisconsin to
    Starkville, Mississippi, to continue supporting match relationships for
    a third year.
        It is our understanding that the cost of restoring the third year
    of funding for 2008 mentoring program grantees is estimated at $17
    million.
        Mentoring is fundamentally predicated on creating healthy and
    meaningful relationships for youngsters who are in jeopardized
    circumstances with respect to their potential for achieving long-term
    educational and socio-emotional success. Research demonstrates that
    youth who successfully transition from risk-filled backgrounds to
    responsible adulthood are consistently distinguished by the presence of
    a caring adult in their lives. Prematurely ending matches, such as
    those that have been recently established through the mentoring program
    grants, can be potentially harmful to mentees. MCG strongly urges the
    subcommittee to prevent this possibility from turning into a tragic
    reality for thousands of vulnerable children.
        The ED mentoring program, authorized under the No Child Left Behind
    Act (NCLB) of 2002, section 4130, is a competitive Federal grant
    program managed by the Office of Safe and Drug Free Schools (OSDFS). It
    addresses the lack of supportive adults at critical turning points in
    the lives of youngsters in grades 4-8. The funding supports mentoring
    programs operating in local education agencies (LEAs); nonprofit
    community- and faith-based organizations; and partnerships between LEAs
    and local nonprofits. Funded programs are designed to:
      --improve interpersonal relationships with peers, teachers, family
            members, and other adults;
      --increase personal responsibility and community involvement;
      --discourage the use of drugs and alcohol;
      --discourage the use of weapons;
      --reduce delinquency;
      --improve academic achievement; and,
      --reduce school dropout.
        Since 2004, MCG has worked on-site with 57 ED mentoring program
    grantees serving in the capacity of overall technical assistance
    provider, e.g., mentor/mentee training, mentor recruitment, marketing,
    sustainability planning, and/or as the external evaluator. Our client
    sample is rich with diversity both with respect to the size and scope
    of their grants, e.g., we work with the agency receiving the smallest
    of the 2008 awards, as well as their experience in operating a formal
    mentoring program. Another of our clients, also a 2008 grantee, is
    among the 30 largest school districts in Texas and is working with 17
    partnering school campuses. This grantee exceeded their 1 to 1 match
    goal of 150 matches before the end of the first year of the grant. The
    potential impact on 150 youngsters, in this one community alone, should
    this program be eliminated, is unimaginable.
        A key ``lesson learned'' based on our experience with all of these
    clients is that the complexities of operating a mentoring program
    cannot be overstated. Building safe and secure relationships between
    youngsters and caring adults requires the attention and involvement of
    trained, committed, and competent staff who understand the quality
    assurance standards of the mentoring field.
        Beyond the potential benefits for the youth, the ED mentoring
    program has enabled grantees to forge strategic community partnerships
    between concerned citizens and multiple youth serving organizations to
    maximize the use of community resources. Also negatively affected by
    this proposed termination of funds is those staff hired to work with
    the ED mentoring program who have worked diligently over the past 13
    months to introduce and promote these programs in their community and
    to build these vital new mentor/mentee relationships. Premature
    termination of this grant program would, of course, force layoffs in
    110 communities across the country. By contrast, the economic stimulus
    package is working hard to counter just such layoffs.
        Research over the past decade has demonstrated that mentoring is a
    viable intervention strategy that holds considerable promise. Studies
    of structured mentoring programs, including those that have received
    Federal funding, suggest that the programs are likely to be more
    successful when they include a strong infrastructure and facilitate
    caring relationships. Infrastructure refers to a number of activities
    including identifying the youth population to be served and the
    activities to be undertaken, screening and training mentors, supporting
    and supervising mentoring relationships, collecting data on youth
    outcomes, and creating strategies for long-term sustainability. (Ref.
    Jean Balwin Grossman, ed., Contemporary Issues in Mentoring, Public/
    Private Ventures, p.6). The ED mentoring program is providing much
    needed funding to ensure the integrity of the requisite infrastructure
    and facilitation of caring relationships in programs that would
    otherwise be severely marginalized.
        Another signal research finding is that mentoring relationships are
    likely to promote positive outcomes for youth and avoid harm when they
    are close, consistent, and enduring. (Ref. Rhodes and DuBois,
    ``Understanding and Facilitating the Youth Mentoring Movement,'' p. 9).
    Closeness is the bond that is created between the youth and mentor. The
    characteristics of the volunteer mentors (no mentors in ED mentoring
    program matches are able to be remunerated) have also proven to be
    important in shaping the relationships and strengthening the bond. For
    example, individuals with prior experience in helping roles or
    occupations, an ability to understand and respect cultural differences,
    and an overall sense of commitment to mentoring all appear to
    contribute positively to the relationship and overall match quality.
    Further, it appears that relationships may be especially beneficial
    when they remain part of the youth's life for multiple years (Klaw,
    Fitzgerald & Rhodes, 2003: McLearn et al., 1998) and have the
    opportunity to facilitate adaptation throughout significant portions of
    their development (DuBois & Silverthorn, 2005b; Werner, 1995). These
    findings are of particular importance to the 4th through 8th grade
    population served by the ED mentoring program.
        The ED mentoring program garnered national attention recently
    following publication of the Impact Evaluation of the U.S. Department
    of Education's Student Mentoring Program report prepared by Abt
    Associates for the Institute of Education Sciences (March 2009). ED
    contracted with Abt in 2005 to conduct the study which used an
    experimental design in which students were randomly assigned to a
    treatment or control group. The study involved 32 ED Mentoring Program
    grantee sites that were funded beginning in 2004 or 2005. Grantees
    selected for participation in the Impact Study were required to meet
    three criteria:
      --Be operational so that it could recruit and match students to
            mentors in the fall of 2005 for the first group of grantees and
            fall 2006 for the second group;
      --Able to oversubscribe or identify excess demand supporting
            experimental study needs for an unserved control group (i.e.,
            able to provide tangible evidence of a pool of 4th through 8th
            grade students referred to the mentoring program) of adequate
            size to support study requirements; and
      --Willing and able to cooperate with the data collection and
            logistical needs of the national evaluation, including random
            assignment.
        While the findings of the impact evaluation study are indeed mixed,
    MCG is encouraged that this study has captured several of the inherent
    challenges that often confront early cohorts of federally funded
    mentoring initiatives. This study contributes to the growing body of
    research evidence, however, the field warrants additional comparative
    evaluation studies that look at different program models. Each and
    every cohort of a federally funded initiative should be evaluated and
    this study helps to make that very point. More recently funded ED
    mentoring program grantees, including those in 2008, have had the
    benefit of an expanded comprehensive technical assistance package that
    includes conference trainings, webinars, resource materials (available
    online), and site visits designed to help program coordinators with all
    aspects of program implementation, data tracking, and operation. In
    addition, grantees are now trained on specific aspects of program
    sustainability.
        In closing, we would like to share with you a comment from a mentee
    who met with us during a recent site visit. When asked what having a
    mentor meant to him, Isaiah, a fourth grade student replied, ``Having a
    mentor has been the best thing that has happened to me in my whole
    life.''
        MCG fully acknowledges and appreciates the widespread economic and
    social challenges facing our country at this time. However,
    reinstatement of the ED mentoring program funding in the 2010 budget is
    a clarion call for moral policymaking.
        That call is befitting of your role as members of this august body
    and will ensure that youngsters like Isaiah will one day achieve their
    full potential and enjoy their opportunity to sit as a distinguished
    member of Congress.
        Thank you for the opportunity to submit this testimony.
                                     ______

         Prepared Statement of the Montgomery County Stroke Association
        I am Flora Ingenhousz, a psychotherapist in private practice in
    Silver Spring, Maryland. I have always been in excellent health and
    live an active, healthy lifestyle. Doctors always commented on my low
    blood pressure and my excellent cholesterol numbers. But I suffered a
    stroke 3 years ago. It was a shock to me and my family, friends, and
    clients.
        One morning 3 years ago, when doing a load of laundry, I had no
    idea how to set the dials, despite the fact that I had used them weekly
    for the last 10 years. I stood there for what seemed an eternity before
    I figured out how to set the dials.
        Next, I went to do yoga. In one of the poses, I noticed my right
    arm was hanging limp. When my husband asked me a question, my answer
    was just the opposite of what I wanted to say. I caught my error and
    tried again, but it soon became clear that something was wrong. My
    symptoms kept getting worse.
        When we walked into the emergency room (ER), my right leg was weak,
    and I could not sign my name at the desk. Twelve hours later, I could
    not move my right side, and my speech was reduced to ``yes'' and
    ``no''. Not a good thing for a psychotherapist, where language is a
    primary tool.
        In the emergency room, a CT scan showed a hemorrhagic or bleeding
    stroke where an artery burst, destroying millions of brain cells within
    minutes, affecting my speech and my ability to perform activities like
    dressing in the correct order. Also, my right arm and leg were
    extremely weak. However, I could understand everything, and I was never
    completely paralyzed. But, I was scared.
        I was in intensive care for 4 days of observation and lots of
    testing, but the tests provided no answers. Two days after my stroke,
    while still in intensive care, I started occupational, physical, and
    speech therapy. It was extremely challenging to feed myself with my
    right hand, requiring all my concentration. After a meal or brushing my
    teeth, I was exhausted. Speaking was the hardest of all. My brain
    seemed devoid of words.
        After being stabilized, I was transferred to the National
    Rehabilitation Hospital. For a week, I endured speech, physical,
    occupational and recreational therapies.
        Speech therapy was the hardest, but also the most important given
    my profession. Several times, the speech therapist challenged me to the
    brink of tears.
        After a week at the Rehabilitation Hospital, I went home and to
    outpatient therapies. Speech therapy lasted the longest. After being
    discharged from speech therapy, I still had deficits in my
    organizational skills and abstract thinking.
        As I struggled with starting to see my clients again, I slid into a
    deep depression. I was not confident that I could continue to practice.
    For months, I saw no point in living. Recovery from my poststroke
    depression was harder than the recovery of my arms and legs and even
    speech.
        Being a psychotherapist, I know how to treat depression, so I went
    to a psychiatrist who prescribed anti-depressant medication and, I also
    found a psychotherapist.
        After months on anti-depressants and excellent psychotherapy, my
    depression began to lift. I continue on the drugs and to see my
    psychotherapist. Emotionally, the aftermath of my stroke cut deep.
        I am fortunate that 3 years poststroke, I am back to my practice
    full time. I lead support groups for stroke survivors and caregivers
    through the Montgomery County Stroke Association and served on its
    Board. I now lecture on stroke, stroke prevention and stroke recovery.
    I founded ``hope for stroke''--individual and family counseling for
    stroke survivors and caregivers. And I have developed, together with a
    colleague, a seminar for professionals in the stroke field on the role
    of mental health providers in stroke recovery. In addition, I have
    participated in a National Institutes of Health (NIH) study about
    stroke recovery.
        Once again, I am in excellent health and have resumed my active
    lifestyle. I thank my brain for having the capacity to work around the
    dead cells. But most of all, I thank my therapists for my recovery.
    Their ability to zero in so effectively would not have been possible
    without NIH research.
        Because stroke is a leading cause of death and disability and major
    cost to society, I urge you to provide stroke research with a
    significant funding increase. I am concerned that NIH continues to
    invest only 1 percent of its budget in stroke research.
        Thank you.
                                     ______

                          Prepared Statement of MENTOR
        Chairman Harkin and Ranking Member Cochran, we thank you for the
    opportunity on behalf of MENTOR to submit written testimony in support
    of resources for youth mentoring.
        Primarily, this includes $100 million in Federal funding for youth
    mentoring--$50 million for the Department of Health and Human Services'
    Mentoring for Children of Prisoners program and $50 million for the
    Department of Education's Mentoring Programs grants. MENTOR has
    appreciated the support of the subcommittee in previous years, in
    funding these programs at these levels since fiscal year 2004.
        Mentoring has been recognized as an important form of service by
    the Obama administration and the 111th Congress, given its inclusion in
    several portions of the recently signed Edward M. Kennedy Serve America
    Act. The act, in its wide-ranging call to significantly increase
    service opportunities, will also augment the pool of volunteers who can
    become mentors to young people.
        We would like to appeal that the Serve America Act be fully funded
    in fiscal year 2010 to ensure that this historical boost in national
    and community service is allowed to occur. We also are recommending
    that Congress continue to provide $50 million each for the U.S.
    Department of Education Mentoring Programs grants and the U.S.
    Department of Health and Human Services' Mentoring for Children of
    Prisoners program.
        Background on MENTOR and Youth Mentoring.--MENTOR is the Nation's
    leading advocate and resource for mentoring, delivering the research,
    policy recommendations, advocacy, and practical performance tools that
    facilitate the expansion of mentoring initiatives. We believe that,
    with the help and guidance of an adult mentor, each child can unlock
    his or her potential.
        For nearly two decades, MENTOR has worked to expand the world of
    quality mentoring. In cooperation with a national network of Mentoring
    Partnerships and with more than 4,100 mentoring programs nationwide,
    MENTOR helps connect young Americans who want and need caring adults in
    their lives with the power of mentoring.
        We build the infrastructure that enables mentoring programs to
    flourish, and we leverage resources and provide tools that local
    mentoring programs need to operate high-quality mentoring. We also
    assist mentoring programs nationwide in building greater awareness of
    the need for mentors, and raising the profile of mentoring among
    corporate leaders, foundation executives, policymakers and researchers.
        Three million young people are currently benefiting from the
    guidance of caring adult mentors under our system. And through the
    combined efforts of the mentoring field, we seek to close the mentoring
    gap so that the 15 million children who currently need mentors also can
    benefit from caring mentors.
        It is on behalf of these 4,100 mentoring programs, the national
    network of mentoring partnerships and 15 million children who need
    mentors all across our country that we submit this testimony today.
        Benefits of Mentoring.--Youth mentoring is a simple, yet powerful
    concept: an adult provides guidance, support and encouragement to help
    a young person achieve success in life. Mentors serve as role models,
    advocates, friends and advisors.
        Mentoring today offers many options--the traditional one-to-one
    format, team and group mentoring, peer mentoring, and even online
    mentoring. And mentoring programs are run by nonprofit community-based
    organizations, schools, faith-based organizations, local government
    agencies, workplaces, and more.
        Numerous program evaluations have demonstrated that high-quality
    mentoring relationships can lead to a range of positive outcomes. A
    meta-analysis of 55 mentoring program evaluations found benefits of
    participation in the areas of emotional/psychological well-being,
    involvement in problem/high-risk behavior and academic outcomes.
    Looking at a broader range of outcomes, conducted a meta-analysis of 40
    youth mentoring evaluations, and found that youth in mentoring
    relationships fared significantly better than nonmentored youth.
    Likewise, a recent, large randomized evaluation of Big Brothers Big
    Sisters of America's newer, school-based mentoring revealed
    improvements in mentored youth's academic performance, perceived
    scholastic efficacy, school misconduct, and attendance relative to a
    control group of nonmentored youth. In short, mentoring is an effective
    strategy that addresses both the academic and nonacademic needs of
    struggling young people. It can help ensure that students come to
    school and are ready and able to learn.
             high-quality mentoring generates the strongest impact
        Like any youth-development strategy, mentoring works best when
    measures are taken to ensure quality and effectiveness. Money,
    personnel and resources are required to initiate and support quality
    mentoring relationships. The average per-child expenditure for a
    mentoring match that adheres to The Elements of Effective Mentoring
    PracticeTM--the mentoring industry standard--is between
    $1,000 and $1,500 per year, depending on the program model.
        Successful mentoring programs must have well-trained staff familiar
    with the needs of the community. One-third of mentoring programs
    indicate that hiring and retaining quality staff can be a challenge due
    to low salaries. A recruitment campaign must be conducted to attract
    volunteers, as many programs have young people on their waiting lists
    for mentors.
        Program staff must interview each potential volunteer, check
    references, and perform criminal background checks. Thorough background
    checks alone can cost as much as $50-$90 per volunteer. Once the
    screening process is complete, each mentor must receive first-rate
    training before being matched with a mentee. The work of the mentoring
    program does not end with the first meeting of the mentor and young
    person--both require ongoing support, monitoring, and guidance.
        All of these elements are critical because research clearly links
    program quality with positive outcomes. According to Dr. Jean Rhodes,
    professor of psychology at University of Massachusetts at Boston,
    careful screening, training and ongoing support are essential to the
    longevity of mentoring relationships and to the ultimate success of
    mentoring relationships.
        Rhodes also found that the longer a mentoring relationship lasts,
    the greater the positive, long-lasting effect it has on a young person.
    Other researchers in the field have substantiated her findings. In
    essence, when properly prepared and supported, a mentor is more likely
    to connect with the young person and to stick with the relationship
    when times get hard.
        Need for Federal Dollars.--The mentoring field needs continued
    access to Federal funds if we are to be able to serve more children,
    and serve them well. Once again, America has a wide mentoring gap of
    nearly 15 million young people. The demand for mentoring far exceeds
    the current capacity of local mentoring programs and the number of
    adults who volunteer as mentors, and thousands of children sit on
    waiting lists for mentors. As noted above, it takes financial resources
    to be able to adhere to mentoring best practices and provide quality
    mentoring experiences to young people.
        Since fiscal year 2004, Congress has devoted approximately $100
    million annually for youth mentoring, split evenly between two critical
    grant programs:
      --Department of Education, Mentoring Programs Grants.--These grants
            go to local mentoring organizations to establish or expand
            their mentoring program. It can support recruiting, screening,
            and training of mentors, as well as hiring and professional
            development of mentoring coordinators and support staff.
            Community-based organizations, faith-based organizations, and
            schools are eligible to apply for funding.
      --Department of Health and Human Services, Mentoring for Children of
            Prisoners.--This program provides funding to organizations that
            match mentors with young people whose parents are incarcerated.
            It also is open to community-based and faith-based
            organizations.
        Both of these programs provide much-needed Federal dollars to help
    mentoring programs get established or to expand to serve more children.
    Both programs are competitive grant programs, with all funding being
    awarded to local organizations. The request for proposals for both
    programs require applicants to detail how they will be able to carry
    out key mentoring best practices. Since 2004, coinciding with this
    significant increase in Federal support, we have seen the number of
    young people in mentoring relationships grow from 2.5 million to the
    current level of 3 million. Clearly, this funding is having an impact
    on the mentoring gap.
        President Obama stated in remarks about his fiscal year 2010 budget
    February 26, 2009, ``Education Secretary Duncan is set to save tens of
    millions of dollars more by cutting an ineffective mentoring program
    for students, a program whose mission is being carried out by 100 other
    programs in 13 other agencies.'' Once again, we are not certain that
    this means the total elimination of school-based mentoring programs in
    the Department of Education, but even in the absence of a detailed
    budget justification, we feel that comment is warranted.
        We understand that this decision may rest in large part on a recent
    evaluation that showed that school-based mentoring, as practiced by
    many programs around the country, failed to increase grades or test
    scores. However, just 2 years ago, another rigorous evaluation of
    school-based mentoring found that teachers reported the quality of the
    mentored students' school work improved.
        To understand these apparently contradictory findings, it is
    important to note that the earlier evaluation answered the question,
    ``What effect does a well-run, school-based mentoring program have?''
    The more recent evaluation answered the question, ``What effect does
    the average school-based mentoring program have?'' Findings from both
    studies reveal that strong programs can improve academic performance,
    while programs that do not incorporate best practices cannot.
    Interestingly, both types of programs have increased attendance.
        School-based mentoring was never designed to be a program that
    primarily improved academic achievement. Mentoring aims more broadly to
    keep children on a constructive, responsible path (such as encouraging
    behaviors like coming to school and following the rules). Mentors are
    not supposed to be teachers, but friends and role models. Even so, the
    earlier evaluation did show that well-run programs improved academic
    performance and behavior by the end of the school year.
        Mentoring addresses a particular challenge facing our Nation today:
    the high rate at which young people drop out of high school. Nearly
    one-third of all high school students drop out before receiving their
    diploma, a rate which approaches 50 percent for minority students.
    Research on the dropout rate shows that young people can fail to
    graduate for a wide variety of reasons, including: lack of connection
    to the school environment, lack of motivation or inspiration, chronic
    absenteeism, lack of parental involvement, personal reasons such as
    teen pregnancy, and failing in school.
        We know that young people who drop out will face a future of
    unemployment, Government assistance, and even criminal involvement. We
    need to help these young people before they reach the point of dropping
    out of high school. Fortunately, youth mentoring can play in important
    role in addressing the issues young people face within the learning
    environment. Research demonstrates that many of the impacts of
    mentoring can directly address the underlying causes of our Nation's
    dropout crisis. Specific impacts of mentoring include:
      --Mentored youth feel greater competence in completing their
            schoolwork, which is linked to higher levels of classroom
            engagement and higher grades.
      --School-based mentoring enhances connectedness to schools, peers and
            society, and mentored youth have more positive attitudes toward
            school and teachers;
      --Evaluations of mentoring programs indicated that both one-to-one
            mentoring and group mentoring result in better school
            attendance for mentored youth;
      --Mentored youth experience improvements in parental relationships
            and their own sense of self-worth; and
      --Mentored youth are significantly less likely to participate in
            high-risk behaviors, including substance abuse, carrying a
            weapon, unsafe sex, and violent behaviors.
        Mentoring is an important tool to help address dropout risk factors
    and help ensure that young people are supported in their effort to
    graduate from high school and make a successful transition to
    adulthood.
        These are tough economic times that warrant tough decisions.
    However, rather than eliminating or cutting funding for school-based
    mentoring, Congress and the administration could restrict the funding
    to programs that truly incorporate best practices--the kind of programs
    that have been shown to produce results. MENTOR recommends that the
    request for proposals issued for the program be revisited to ensure
    that it focuses on the key functions mentoring programs must perform
    and their adherence to The Elements of Effective Mentoring Practice--
    research-based industry standards now in their third edition. These
    standards work to ensure that programs do their utmost to ensure that
    mentoring does, in fact, work for America's young people by providing
    the best mentoring experience possible. Within the Elements, Program
    Design and Planning includes comprehensive guidelines to launch an
    effective new mentoring initiative. Program Management and Program
    Operations contain guidelines for managing and implementing the many
    elements of a new program or fine-tuning certain elements for an
    established program. Program Evaluation provides guidance for analyzing
    a program to ensure it is safe, effective and able to meet its goals.
    It is important to ensure that funding is going to high-quality
    programs with real potential to make a difference, rather than
    dismantle a strong infrastructure for service that is now in place in
    thousands of American schools.
        Thus, MENTOR recommends that $50 million once again be provided to
    the Department of Education's Mentoring Programs grants in fiscal year
    2010. Some of this funding is needed to simply support commitments
    already made to existing grantees. All grants awarded under this
    program are 3-year projects and require continued appropriations. We
    also expect new grants to be made out of fiscal year 2009 funding,
    approved at $48.5 million. Those organizations that see their funding
    terminate early would likely have to downsize or even close. This would
    likely result in the premature end to hundreds--if not thousands--of
    mentoring relationships. Research shows that when mentoring
    relationships terminate unexpectedly, it can have a detrimental impact
    on the child.
        Besides the immediate 1-year impact, the elimination of this
    program will mean the end of the only authorized Federal program
    specifically focused on providing mentors for young people at risk of
    failing academically--this is not a function that is duplicated in many
    programs more than 13 different agencies as the President mentioned in
    February. In the 7 years the program has been in existence, more than
    600 grants have been awarded to local mentoring programs in every
    State, including rural, suburban, and urban settings. These grants have
    totaled nearly $300 million. At the average per-child mentoring cost of
    $1,500 per year, this means that approximately 200,000 young people are
    benefiting from a mentoring relationship that otherwise likely would
    not have been possible.
        To conclude this portion of my testimony, we respectfully request
    that Congress provide $50 million each for the Department of Education
    Mentoring Programs grants and the Department of Health and Human
    Services Mentoring Children of Prisoners program.
        The Call to Fund Service.--MENTOR joined the strong ranks of
    community organizations delighted when the Edward M. Kennedy Serve
    America Act became law last week. With significant, bi-partisan
    support, this legislation provides for the largest expansion of
    national and community service since the 1930s and expands major
    initiatives, such as AmeriCorps and the Retired Senior Volunteer
    Program, which emerged during the course of the past 20 years. The
    legislation also includes key new provisions that recognize mentoring
    as an important form of national and community service and support its
    growth.
        As enacted, the Serve America Act provides many more opportunities
    to support quality mentoring. For example, mentoring is an eligible
    activity for those engaged in the newly expanded AmeriCorps, Volunteers
    In Service To America (VISTA) and Retired and Senior Volunteer
    Programs, as well as the newly created Education Corps and Veterans'
    Corps. In addition, mentoring partnerships, which support the expansion
    of quality mentoring in many States throughout the country, are now
    eligible for funding through the National Service Trust Program and
    Volunteer Generation Fund.
        Now that it is authorized, it is doubly important that the act's
    provisions be funded properly in fiscal year 2010 and beyond. mentoring
    programs and our national network of Mentoring Partnerships already
    rely on the tremendous contributions that AmeriCorps and VISTA
    volunteers make, as mentors to youth in need and staff support at those
    organizations. The boost in service represented by the Serve America
    Act would allow programs and Partnerships to make an even more
    meaningful impact in our communities and help us close the gap of 15
    million young people who want and need high-quality mentoring
    relationships.
                                   conclusion
        On behalf of the thousands of mentoring programs and millions of
    mentored children across the country, we commend you for your past
    support of mentoring and national and community service funding. We
    strongly encourage you to continue this wise investment in our young
    people and in our country. Thank you for your consideration.
                                     ______

                    Letter From Maui Family Support Services
                                             Wailuku, HI, May 12, 2009.
    Hon. Tom Harkin,
    Chairman, Subcommittee on Labor, Health and Human Services, and
            Education, and Related Agencies, Washington, DC.
        I write to express support for increased funding for the Child
    Abuse Prevention and Treatment Act (CAPTA) programs. We propose to
    increase CAPTA basic State grant funding to $84 million, community-
    based prevention grants funding to $80 million, and research and
    demonstration grants funding to $37 million in fiscal year 2010.
        CAPTA's title II authorizes grants to States to help develop
    community-based prevention services to support families, including
    parenting education classes, home visiting services, respite care, as
    well as family resource centers to connect families and children to the
    services they need. While we spend billions of dollars every year on
    foster care to protect the children who have been the most seriously
    injured, we can do a much better job at protecting children before the
    damage is so bad that we have no other choice than to remove them from
    their homes. Community prevention services to at-risk families are far
    less costly than the damage inflicted on children from abuse and
    neglect. Increasing for CAPTA prevention grants to $80 million would
    help communities support proven, cost-effective approaches to
    preventing child abuse and neglect.
        It is extremely important that we give the highest priority to the
    children of this Nation for they are the most vulnerable population
    that needs protection and support to grow into a well-balanced,
    healthy, and productive citizenry.
        Thank you for your time and consideration.
                                                      Ave Diaz,
                                Healthy Start Home Visiting Supervisor.
                                     ______

    Prepared Statement of the National Association of Anorexia Nervosa and
                              Associated Disorders
        Founded in 1976, the National Association of Anorexia Nervosa and
    Associated Disorders (ANAD) is our Nation's first nonprofit
    organization dedicated to education, early detection, and prevention of
    anorexia nervosa, bulimia nervosa, binge eating disorder, obesity, and
    related eating disorders.
        Eating disorders are severe mental illnesses which often have
    significant physical health consequences for their victims, including
    malnutrition, obesity, and diabetes, as well as death due to cardiac
    arrest, organ failure, blood imbalances, and suicide. Anorexia nervosa
    has the highest mortality rate of any mental illness. An estimated 6
    percent of those who have the disease die as a result. These disorders
    also frequently lead to or co-occur with other serious illnesses such
    as severe depression, alcoholism, and drug abuse.
        Eating disorders are at epidemic levels in America. An estimated 7
    million women and 1 million men have eating disorders. These illnesses
    affect all segments of society--the young and old, the rich and poor,
    and all races and ethnicities, including African Americans, Asian
    Americans, Latino Americans, and Native Americans. But this is an
    epidemic that can be averted with education and prevention programs,
    and cured with early diagnosis and appropriate treatment.
        Data from an ANAD survey of 18 middle and high schools in 15 States
    indicates that eating disorders are almost as prevalent as alcohol or
    drug problems among female middle school and high school students. The
    survey also indicates that our schools are spending far less time on
    eating disorder prevention than on alcohol or drug prevention programs.
    Seventeen percent of the schools surveyed spent 1 hour per year on
    eating disorder education. Eleven percent of the schools surveyed had
    no eating disorder prevention program of any kind.
        The failure to fund eating disorder education and prevention in
    schools is especially troubling in light of the fact that eating
    disorders are often accompanied by or lead to alcoholism or drug
    addiction, as well as diabetes, severe depression, and suicide.
        Tens of millions of dollars are spent each year at the local,
    State, and Federal levels to ensure that our children are properly
    educated to the dangers of alcohol and drugs. The value of such
    programs has been proven and accepted in schools throughout the
    country. With eating disorders almost as prevalent as alcohol and drug
    abuse in our schools, it is imperative that we provide more support for
    eating disorder prevention efforts in our middle schools and high
    schools. Millions of our youth can benefit from proven, low-cost
    educational and preventive measures that help faculty and students to
    understand and avoid the dangers of eating disorders.
        Eating disorder research into the underlying causes and risk
    factors associated with eating disorders is just as important as
    education and prevention. As we continue to learn more about underlying
    causes, risk factors and predictors through medical research, it will
    undoubtedly improve the efficacy of our education and prevention
    efforts.
        Based on the foregoing, ANAD respectfully makes this request of the
    subcommittee with regard to funding priorities for fiscal year 2010.
    Millions of our youth can benefit from proven, low-cost services that
    assist students to understand and avoid the dangers of eating
    disorders. Programs, such as those provided by ANAD's Eating Disorders
    and Obesity Education/Prevention Program for Middle and High Schools,
    promote the elements of a healthy lifestyle: self-acceptance, a good
    diet, adequate exercise and sufficient sleep.
        Given the troubling lack of education and prevention in our
    schools, ANAD respectfully requests $4 million or $75.00 per school be
    allocated to place these life-enhancing programs in every middle and
    high school in the United States. This $4 million in funds is above and
    beyond the current request in the administration's proposed budget, for
    the Department of Education's Safe and Drug-Free Schools programs to
    provide grants for eating disorder prevention and education programs in
    our Nation's middle schools and high schools.
        Eating disorders cause serious physical problems that can last a
    lifetime. They rob people of their ability to function as productive
    members of society because, if not properly treated, victims of these
    illnesses find themselves requiring more and more costly medical
    services throughout their lives. With early education and detection,
    eating disorders are treatable and at a much lower economic and
    personal cost to society.
                     summary of anad eating disorders study
        Data from a 2005 ANAD study shows that eating disorders are almost
    as prevalent as alcohol or drug problems in middle and high school
    female students. The study also shows that far less time is spent on
    eating disorder prevention than on alcohol or drug prevention programs.
        This is especially significant since eating disorders are often
    accompanied by or lead to severe depression, suicidal tendencies, self-
    mutilation, or diabetes. Many victims become alcohol or drug addicted.
        Eating disorders cause great suffering for victims and families and
    are expensive to treat. Anorexia nervosa has the highest mortality rate
    of any mental illness. An estimated 6 percent of all anorexics die from
    an eating disorder or from complications from their disorder. However,
    these very dangerous illnesses can be cured and prevented.
        Eight middle schools and 10 high schools from 15 States were
    surveyed for this study.
    Incidence of Alcoholism, Drugs, and Eating Disorders in Schools
        Nine point eight percent of girls have problems with alcohol; 8
    percent of girls have problems with drugs; and 7.8 percent of girls
    have problems with eating disorders.
    Time Devoted to Education/Prevention
        Time devoted to Alcohol Education/prevention--12.3 percent; time
    devoted to Drugs Education/Prevention--13.8 percent; and time devoted
    to Eating Disorders Education/prevention--6.2 percent.
        Three schools reported 1 hour per year was spent on eating
    disorders education and two schools reported that they did not have any
    program.
                                     ______

       Prepared Statement of the National Association of County and City
                                Health Officials
        The National Association of County and City Health Officials
    (NACCHO) represents the Nation's approximately 2,860 local health
    departments (LHDs). These governmental agencies work every day in their
    communities to prevent disease, promote wellness, and protect health.
    They organize community partnerships and facilitate community
    conversations to create the conditions in which people can be healthy.
    The work of local health departments and NACCHO improves economic well-
    being, educational success, and nationwide competitiveness community by
    community.
        The current H1N1 influenza cases in the United States could signal
    the onset of the next pandemic. State and local public health agencies
    are actively engaged in outbreak investigation, control and response
    activities to control the virus' spread and minimize illness and death.
    NACCHO appreciates the past support of the subcommittee for public
    health emergency preparedness and urges the subcommittee to provide the
    necessary resources so that State and local health departments are able
    to respond to all hazards, including a possible resurgence of pandemic
    influenza in the fall.
        LHDs have a unique and distinctive role and set of responsibilities
    in the larger health system and within every community. The Nation
    depends upon the capacity of local health departments to play this role
    well. A LHD is the only local governmental entity that works from a
    population-wide perspective. LHDs have statutory powers which enable
    their role and enshrine a duty to serve every person and household in
    their jurisdiction.
        Funding to local health departments continues to be inadequate and
    many people in the United States suffer from conditions whose causes
    are preventable, whose costs for treatment are unsustainable into the
    future, and whose treatment is of erratic quality, effectiveness and
    efficiency. One clear, measured result is that the United States is not
    the healthiest Nation in the world despite higher per capita
    expenditures than any other Nation.
        The Nation's current recession further diminishes the ability of
    local health departments to measure population-wide illness and death,
    organize efforts to prevent disease and prolong quality of life, and to
    serve the public through organized programs not offered elsewhere.
    Repeated rounds of budget cuts and layoffs in LHDs continue to erode
    capacity. Reductions in local and State tax bases further undermine
    these sources of support. A NACCHO survey found that in 2008, at least
    7,000 LHD jobs were lost in 46 States across the country. Far more are
    expected this year and many LHDs are currently reporting budget cuts in
    the 20 to 40 percent range.
        Protections people take for granted--from enforcement of rules
    requiring safe food in restaurants and schools to early identification
    of disease outbreaks to the expectation that their LHD will examine,
    discover, and take action--are disappearing. In economic hard times,
    people are more dependent than ever on their local health departments.
    Programs offered by LHDs serve as a safety net for people in
    communities where the numbers of unemployed, uninsured, and
    underinsured are growing daily, compounding the numbers of formerly
    working adults who need care.
        NACCHO's recommendations focus on the Centers for Disease Control
    and Prevention (CDC) and the Health Services and Resources
    Administration (HRSA). Consistent funding with growth over time is
    needed. NACCHO recommends an overall funding level for CDC of $8.6
    billion not including funding for Vaccines for Children.
                chronic disease prevention and health promotion
    Preventive Health and Health Services Block Grant
        NACCHO recommends: Not less than fiscal year 2005 funding of $131
    million. Local public health departments receive approximately 40
    percent of the Preventive Health and Health Services block grant (PHHS)
    nationally. The proportion received by local health departments varies
    among states from less than five percent to almost 100 percent.
    Increasing the availability of flexible funds is particularly important
    as the gaps in public health protections grow.
        PHHS funds enable States to address critical unmet public health
    needs. Improving chronic disease prevention through screening programs
    and programs that promote healthy nutrition and physical activity are
    prime examples of activities to which many jurisdictions devote PHHS
    funds. Population-based strategies which create the conditions in which
    people are more likely to be healthy are also supported with these
    funds. Flexible PHHS funds allow local priorities and unexpected
    problems to be addressed. West Nile virus, a fully preventable disease
    spread to humans by mosquitoes, is one good example. Finally, PHHS
    funds provide leverage for additional support from non-Federal sources.
        NACCHO also recommends that the subcommittee include language with
    the appropriations bill which would require concurrence of LHDs with
    State public health officials in the uses for and distribution of these
    funds. Such language has been instrumental in the effective use of
    preparedness funds, assuring that a reasonable proportion of funds help
    local communities.
                             emergency preparedness
    Public Health Emergency Preparedness Cooperative Agreement
        NACCHO recommends not less than fiscal year 2005 funding of $919
    million. Federal funding for improving State and local public health
    emergency preparedness has stalled for the past several years and is
    substantially down from $919 million in fiscal year 2005 to $746
    million in the fiscal year 2009 omnibus appropriations bill. Local
    health departments successfully responded to the outbreak of H1N1
    influenza this spring, but a sustained epidemic would further tax
    resources and stretch the capacity of local health professionals to
    respond adequately to the influenza outbreak as well as other
    responsibilities in the areas of infectious and chronic disease.
        Last year more than 25 percent of LHDs reduced their preparedness
    activities, delayed completion of plans, and/or delayed acquisition of
    equipment and supplies as a result. Constant readiness for both new and
    emerging threats requires staff, plans, training and practice, all of
    which require financial support. The benefits to safety and well-being
    of local communities are clear when LHDs are prepared and work
    effectively with their communities to be prepared for all hazards.
    Reduction in Federal financial support has reduced readiness and the
    capacity to respond to emergencies.
                           advanced practice centers
        NACCHO recommends level funding of $5.3 million plus inflation
    adjustment. NACCHO appreciates the past support of the subcommittee for
    the Advanced Practice Centers program. The Advanced Practice Center
    (APC) program funded through CDC provides funds to seven local health
    departments to develop innovative field-tested tools and models to help
    other LHDs meet emergency preparedness goals. The APCs are located in
    Santa Clara County, California; Cambridge, Massachusetts; Montgomery
    County, Maryland; Twin Cities Metro, Minnesota; Western New York Public
    Health Alliance; Tarrant County, Texas and Public Health--Seattle and
    King County, Washington. The 70 unique preparedness tools produced to
    date by the APCs have become essential instruments that LHDs nationwide
    routinely employ to assess their vulnerability, strengthen their
    response capacity, and enhance the resilience of their communities and
    workforce. The APC network provides a national learning laboratory that
    creates tools, resources, and technical guidance that can be used for
    all LHDs and that align with public health preparedness priority areas.
                            public health workforce
        NACCHO recommends $10 million new funding. The shortages in the
    public health workforce have been well-documented, particularly in
    public health nursing, epidemiology, laboratory science, and
    environmental health. The Nation's wellness depends on a continuing
    supply of people for this workforce. Additional funding and leadership
    is required to support a program of training, continuing education, and
    education for the full range of public health professions and community
    workers. Section 765 of the Public Health Service Act authorizes grants
    that would allow State and local health departments to provide training
    and trainee support. Funds have never been appropriated for this
    purpose.
                        emergency preparedness workforce
        NACCHO recommends $10 million new funding. Workforce shortages also
    exist in the area of public health preparedness. In 2006, the Pandemic
    and All-Hazards Preparedness Act created two new programs within the
    National Health Service Corps (NHSC) in the Health Resources and
    Services Administration, yet no funding was appropriated for these
    programs. Funding would allow expansion of the NHSC on a trial basis to
    include loan repayment for individuals who complete their service in a
    State, local, or tribal health department that serves health
    professional shortage areas or areas at risk of a public health
    emergency. The second program establishes grants to States to create
    loan repayment programs. These programs are essential to ensure a
    workforce trained to carry out specialized tasks in preparedness.
                                     ______

        Prepared Statement of The National Alliance to End Homelessness
        The National Alliance to End Homelessness (the Alliance) is a
    nonpartisan, nonprofit organization that has several thousand partner
    agencies and organizations across the country. These partners include
    local faith-based and community-based nonprofit organizations and
    public sector agencies that provide homeless people with housing and
    services such as substance abuse treatment, job training, and physical
    health and mental healthcare. The Alliance represents a united effort
    to address the root causes of homelessness and challenge society's
    acceptance of homelessness as an inevitable byproduct of American life.
                        summary of appropriations goals
        Moving Forward To End Homelessness.--Communities are using Federal,
    State, and local funds to help homeless persons maintain housing.
    Especially during the current economic recession, it is important that
    this progress not be undermined. To this end, the Alliance recommends
    the following:
      --Allocate $120 million for services for people experiencing
            homelessness within the Programs of Regional and National
            Significance accounts of both Substance Abuse and Mental Health
            Services Administration's (SAMHSA) Center for Mental Health
            Services and Center for Substance Abuse Treatment.
      --Increase funding for the Projects for Assistance in Transition from
            Homelessness (PATH) program to $75 million.
      --Increase funding for the Runaway and Homeless Youth Act (RHYA)
            Programs to $165 million.
      --Provide $2.602 billion in the Community Health Center program
            within the Health Resource Services Administration (HRSA). This
            would result in $226.3 million for the Health Care for the
            Homeless (HCH) program, a $36 million increase from fiscal year
            2009.
      --Fund Education for Homeless Children and Youth (EHCY) services at
            $210 million.
      --Increase funding for the Homeless Veterans Reintegration Program to
            $50 million, its authorized level.
    Connecting Homeless Families, Individuals, and Youth to Mainstream
            Services
        People experiencing homelessness also depend on mainstream
    programs. The Alliance recommends the following to meet this goal:
      --Fund the Social Services Block Grant (SSBG) program at $2.3
            billion.
      --Fund the Community Services Block Grant (CSBG) program at $725
            million.
      --Appropriate $60 million in education and training vouchers for
            youth exiting foster care under the Safe and Stable Families
            Program.
      --Fund the Community Mental Health Services Performance Partnership
            Block Grant at $486.9, a $66.1 million increase.
      --Fund the Substance Abuse Prevention and Treatment Block Grant at
            $1.929 billion, a $150 million increase more than fiscal year
            2009.
                                   background
        Our 2009 report, Homelessness Counts: Changes in Homelessness from
    2005 to 2007, estimates that 671,859 people are homeless on any given
    night. This includes 248,511 persons in families and 423,348
    individuals. Eighteen percent of all homeless people are defined as
    chronically homeless; these are people who have a disability and who
    have been homeless repeatedly or continuously for 12 months. These
    numbers are based on homeless counts performed in 2007, prior to the
    current economic recession. Compared to 2005, there were decreases
    across the country resulting in a 10 percent overall decline in
    homelessness. Anecdotal evidence suggests there could be increases in
    homelessness as communities report the results of their 2009 counts. To
    help stave off drastic increases in homelessness, we need Congress to
    invest in what we know works. Successful interventions for all homeless
    populations couple housing with an appropriate level of services for
    the family or individual. We call on Congress to adequately fund
    programs that assist States and local entities in developing permanent
    housing and the necessary social services to end homelessness for all
    Americans.
                         detailed program descriptions
    Goal No. 1--Moving Forward To End Homelessness
                Support Services for Permanent Supportive Housing Projects
        The Alliance recommends allocating $120 million for services in
    permanent supportive housing within SAMHSA's Center for Mental Health
    Services and Center for Substance Abuse Treatment. Years of reliable
    data and research demonstrate that the most successful intervention to
    solve chronic homelessness is linking housing to appropriate support
    services. Current SAMHSA investments in homeless programs are highly
    effective and cost-efficient.
                                      path
        The Alliance recommends that Congress increase PATH funding to $75
    million and adjust the funding formula to increase allocations for
    small States and territories.
        PATH provides outreach to eligible consumers and ensures that those
    consumers are connected with mainstream services, such as Supplemental
    Security Income, Medicaid, and welfare programs. Under the PATH formula
    grant, approximately 30 States share in the program's annual
    appropriations increases. The remaining States and territories receive
    the minimum grant of $300,000 for States and $50,000 for territories.
    These amounts have not been raised since the program was authorized in
    1991. To account for inflation, the minimum allocation should be raised
    to $600,000 for States and $100,000 for territories. Amending the
    minimum allocation requires a legislative change. If the authorizing
    committees do not address this issue, we hope that appropriators will
    explore ways to make the change through appropriations bill language.
                                 rhya programs
        The Alliance recommends funding the RHYA programs at $165 million.
    RHYA programs support cost effective, community- and faith-based
    organizations that protect youth from the harms of life on the streets.
    The RHYA programs can either reunify youth safely with family or find
    alternative living arrangements. RHYA programs end homelessness by
    engaging youth living on the street with Street Outreach Programs,
    quickly providing emergency shelter and family crisis counseling
    through the Basic Centers, or providing supportive housing that helps
    young people develop lifelong independent living skills through
    Transitional Living Programs. Recently, the Congressional Research
    Service issued a report complimenting the good work of RHYA programs
    but detailing the gaps in services due to limited funding. For example,
    only one-tenth of the youth who connect with a RHYA program are able to
    receive services. It is essential that Congress increase this program.
                   community health centers and hch programs
        The Alliance recommends $2.602 billion in the Community Health
    Center program within HRSA. This would result in $226.4 million for the
    HCH program, a $36 million increase more than fiscal year 2009. Persons
    living on the street suffer from health problems resulting from or
    exacerbated by being homeless, such as hypothermia, frostbite, and
    heatstroke. In addition, they often have infections of the respiratory
    and gastrointestinal systems, tuberculosis, vascular diseases such as
    leg ulcers, and hypertension. Healthcare for the homeless programs are
    vital to prevent these conditions from becoming fatal. Congress
    allocates 8.7 percent of the Consolidated Health Centers account for
    HCH projects.
                education for homeless children and youth (ehcy)
        The Alliance recommends funding EHCY at $210 million. The most
    important potential source of stability for homeless children is
    school. The mission of the EHCY program is to ensure that these
    children can continue to attend school and thrive. EHCY, within the
    Department of Education's Office of Elementary and Secondary Education,
    removes obstacles to enrollment and retention by establishing liaisons
    between schools and shelters and providing funding for transportation,
    tutoring, school supplies, and the coordination of statewide efforts to
    remove barriers.
                 homeless veterans reintegration program (hvrp)
        The Alliance recommends that Congress increase HVRP funding to $50
    million. HVRP, which is within the Department of Labor's Veterans
    Employment and Training Service (VETS), provides competitive grants to
    community-based, faith-based, and public organizations to offer
    outreach, job placement, and supportive services to homeless veterans.
    HVRP is the primary employment services program accessible by homeless
    veterans and is the only targeted employment program for any homeless
    subpopulation. It is estimated that this program only reaches about two
    percent of the overall homeless veteran population. An appropriation at
    the authorized level of $50 million would enable HVRP grantees to reach
    approximately 19,866 homeless veterans.
    Goal No. 2--Connecting Homeless Families, Individuals and Youth to
            Mainstream Services
                       social services block grant (ssbg)
        The Alliance recommends that Congress increase SSBG funding to $2.3
    billion. SSBG funds are essential for programs dedicated to ending
    homelessness. In particular, youth housing programs and permanent
    supportive housing providers often receive State, county, and local
    funds which originate from the SSBG. As the Department of Housing and
    Urban Development has focused its funding on housing, programs that
    provide both housing and social services have struggled to fund the
    service component of their programs. This gap is often closed using
    Federal programs such as SSBG.
                     community services block grant (csbg)
        The Alliance recommends that Congress rejects cuts and fund CSBG at
    $725 million. Funding cuts for CSBG will destabilize the progress
    communities have made toward ending homelessness by not only ending
    services directly provided by CSBG funds but limiting a community's
    ability to access other Federal dollars, such as those provided by the
    Department of Housing and Urban Development. Community Action Agencies
    (CAAs), which are the primary local recipients of CSBG funding, are
    directly involved in housing and homelessness services. In several
    communities, CAAs lead the Continuum of Care (CoC). CoCs coordinate
    local homeless service providers and the community's McKinney-Vento
    Homeless Assistance Grant application process with the Department of
    Housing and Urban Development.
        In the fiscal year 2006 Community Services Block Grant Information
    Systems report published by the U.S. Department of Health and Human
    Services, CAAs reported expending approximately $42 million on housing-
    related services. In addition, approximately $50 million was spent
    nationwide on youth services, some of which related to housing. States
    reported that 180,000 clients served with CSBG funds were homeless.
                  foster youth education and training vouchers
        The Alliance recommends that Congress appropriate $60 million in
    education and training vouchers for youth exiting foster care under the
    Safe and Stable Families Program. The Education and Training Voucher
    Program offers funds to foster youth and former foster youth to enable
    them to attend colleges, universities, and vocational training
    institutions. Students may receive up to $5,000 a year for college or
    vocational training education. The funds may be used for tuition,
    books, housing, or other qualified living expenses. Given the large
    number of people experiencing homelessness who have a foster care
    history, it is important to provide assistance such as these education
    and training vouchers to stabilize youth, prevent economic crisis, and
    prevent future homelessness.
          community mental health performance partnership block grant
        The Alliance recommends that Congress appropriate $486.9 million
    for the Community Mental Health Performance Partnership Block Grant.
    The Mental Health Block Grant provides flexible funding to states to
    provide mental health services. Ending homelessness requires Federal,
    State, and local partnerships. Additional mental health funds will give
    States the resources to improve their mental health system and serve
    all people with mental health disorders better, including homeless
    populations. For example, block grant funds can be used to pay for
    services linked to housing for homeless people, thereby meeting the
    match requirements for projects funded through Shelter Plus Care or the
    Supportive Housing Program.
          substance abuse prevention and treatment (sapt) block grant
        The Alliance recommends that Congress appropriate $1.929 billion
    for the SAPT Block Grant. The SAPT Block Grant is the primary source of
    Federal funding for substance abuse treatment and prevention for many
    low-income individuals, including those experiencing homelessness.
    Studies have shown that half of all people experiencing homelessness
    have a diagnosable substance use disorder. States need more resources
    to implement proven treatment strategies and work with housing
    providers to keep homeless populations, especially chronically homeless
    populations, stably housed.
                                   conclusion
        Homelessness is not inevitable. As communities implement plans to
    end homelessness, they are struggling to find funding for the services
    that homeless and formerly homeless clients need to maintain housing.
    The Federal investments in mental health services, substance abuse
    treatment, employment training, youth housing, veterans' services, and
    case management discussed above will help communities create stable
    housing programs and change social systems which will end homelessness
    for millions of Americans.
                                     ______

    Prepared Statement of the National Alliance for Eye and Vision Research
        National Alliance for Eye and Vision Research (NAEVR) requests a
    fiscal year 2010 National Institute of Health (NIH) funding increase of
    at least 7 percent, to a level of $32.4 billion, which represents a
    modest 3 percent increase plus the biomedical inflation rate, estimated
    at 3.8 percent in fiscal year 2009. This increase is necessary to keep
    pace with inflation and rebuild the base, since NIH has lost 14 percent
    of its purchasing power during the past 6 funding cycles.
        NAEVR commends the congressional leadership's actions in fiscal
    year 2008 and 2009 to increase NIH funding, including the $150 million
    in the fiscal year 2008 supplemental dedicated to investigator-
    initiated grants, the $10.4 billion in 2-year stimulative NIH funding
    within the American Recovery and Reinvestment Act (ARRA), and the final
    fiscal year 2009 appropriations inflationary increase of 3.2 percent.
    However, NIH needs sustained and predictable funding to rebuild its
    base and support multi-year, investigator-initiated research, which is
    the cornerstone of the biomedical enterprise. Annual increases of at
    least 7 percent put NIH on a pathway to budget-doubling within the next
    10 years. Secure and consistent funding for biomedical research is
    integral to the Nation's economic and global competitiveness. NIH is a
    world-leading institution that must be adequately funded so that its
    research can reduce healthcare costs, increase productivity, and save
    and improve the quality of lives.
        NAEVR requests that Congress make vision health a top priority by
    increasing National Eye Institute (NEI) funding by at least 7 percent,
    to a level of $736 million, in this year that NEI celebrates its 40th
    anniversary. Over the past 6 funding cycles, NEI lost 18 percent of its
    purchasing power. Despite funding challenges, NEI has maintained its
    impressive record of breakthroughs in basic and clinical research that
    have resulted in treatments and therapies to save and restore vision
    and prevent eye disease. NEI will be challenged further, as 2010 begins
    the decade in which more than half of the 78 million baby boomers will
    turn 65 and be at greatest risk for developing aging eye disease.
    Adequately funding the NEI is a cost-effective investment in our
    Nation's health, as it can delay, save, and prevent expenditures,
    especially to the Medicare and Medicaid programs.
        Fiscal year 2010 funding at $736 million enables NEI to expand its
    impressive record of basic and clinical collaborative research that has
    resulted in treatments and therapies to save and restore vision.
        NEI continues to be a leader in basic research--especially that
    which elucidates the genetic basis of ocular disease--and in
    translational research, as those gene discoveries can lead to
    development of diagnostics and treatments. NEI Director Paul Sieving,
    M.D., Ph.D., has reported that one-quarter of all genes identified to
    date through NEI's collaboration with the National Human Genome
    Research Institute (NHGRI) are associated with eye disease/visual
    impairment. Recent examples include:
      --In 2005, NEI reported that gene variants of Complement Factor H
            (CFH), the protein product of which is engaged in the control
            of the body's immune response, are associated with increased
            risk of developing age-related macular degeneration (AMD), the
            leading cause of vision loss. NEI-funded researchers are now
            working on potential therapies, including the manufacture and
            use of a protective version of the CFH protein in an
            augmentation strategy similar to that of treating diabetes with
            insulin. This therapy is under development and expected to
            enter phase I clinical safety trials in summer 2009.
      --In March 2008, NEI-funded researchers announced that damage from
            both AMD and diabetic retinopathy was prevented and even
            reversed when the protein Robo4 was activated in mouse models
            that simulate the two diseases. Robo4 treated and prevented the
            diseases by inhibiting abnormal blood vessel growth and by
            stabilizing blood vessels to prevent leakage. Since this
            research into the ``Robo4 Pathway'' used animal models
            associated with these diseases that are already used in drug
            development, the time required to test this approach in humans
            could be shortened, expediting approvals for new therapies
      --In late April 2008, researchers funded by the NEI and private
            funding organization Foundation Fighting Blindness reported on
            their use of gene therapy to restore vision in young adults who
            were virtually blind from a severe form of the
            neurodegenerative disease Retinitis Pigmentosa, known as Leber
            Congenital Amaurosis (LCA). Seven years earlier, the
            researchers shared on Capitol Hill results of a preclinical
            study of the same gene therapy, which at the time was
            successfully giving vision to dogs born blind with LCA. The
            subsequent human gene therapy trial validated the process of
            putting genes in the body to restore vision. Although the
            primary goal of the phase I study was to ensure patient safety,
            the researchers reported through both objective and subjective
            testing that the patients were able to read several lines on an
            eye chart, had better peripheral vision, and better eyesight in
            dimly lit settings. In further research, the investigators will
            treat LCA patients as young as 8 years old, since they believe
            the most dramatic results will be seen in young children.
      --In late 2008, NEI initiated its new NEI Glaucoma Human genetics
            collaBORation, known as NEIGHBOR, through which seven U.S.
            research teams will lead genetic studies of the disease.
            Glaucoma is called the ``stealth robber of vision'' as it often
            has no symptoms until vision is lost, and anywhere from 50-75
            percent of individuals with it are undiagnosed. It is also the
            leading cause of preventable vision loss in African-American
            and Hispanic populations, which emphasizes the vital nature of
            determining the genetic basis of this disease.
    fiscal year 2010 funding at $736 million enables nei to fully fund new
              initiatives that more fully characterize eye disease
        NEI has been a leader in collaborative research, the use of
    networks to study diagnostics and treatments and their use in clinical
    settings, and in ocular epidemiology to characterize the nature and
    frequency of eye disease in diverse populations to better manage pubic
    health. In fiscal year 2008, NEI reported on/launched the initial phase
    of three important new programs to characterize eye disease requiring
    adequate future funding.
      --In early 2009, the NEI and the National Aeronautics and Space
            Administration (NASA) reported on the use of a compact fiber
            optic probe developed for the space program that has proven
            valuable as the first noninvasive early detection device for
            cataracts, the leading cause of vision loss worldwide. Using a
            laser light technique called dynamic light scattering (DLS),
            which was developed to analyze the growth of protein crystals
            in a zero-gravity environment, the probe measures the amount of
            light scattering by an anti-cataract protein called alpha-
            crystallin. The probe senses protein damage due to oxidative
            stress, a key process involved in many medical conditions
            including age-related cataract and diabetes, as well as
            Alzheimer's and Parkinson's disease.
      --In late 2008, NEI launched a new research network, the Neuro-
            Ophthalmology Research Disease Investigator Consortium, or
            NORDIC. It will initially lead multi-site observational and
            treatment trials, involving nearly 200 community and academic
            practitioners, to address the risks, diagnosis, and treatment
            of two ``rare'' diseases: idiopathic intracranial hypertension
            (visual dysfunction due to increased intracranial pressure) and
            thyroid eye disease (also called Graves' disease, in which
            muscles of the eye enlarge and cause bulging of the eyes,
            retraction of the lids, double vision, decreased vision, and
            irritation). The NEI and NORDIC's principal investigator have
            already begun coordinating with the Department of Defense's
            (DOD) newly established Vision Center of Excellence (VCE) about
            the applicability of NORDIC research to combat-related eye
            injuries, especially those associated with Traumatic Brain
            Injury (TBI).
      --There is currently almost no information on the prevalence, risk
            factors, and genetic determinants in Asian Americans--one of
            the fastest growing racial groups in the United States. Studies
            from East Asia have suggested that Asians have a spectrum of
            eye diseases different from that of White Americans, African
            Americans, and Hispanics. In late 2008, NEI launched the
            Chinese American Eye Study to characterize the extent of eye
            disease in Chinese Americans, the largest Asian sub-group in
            the United States. Participants 50 years and older will be
            evaluated for blindness, visual impairment, and eye disease.
            These results will add to the expanding body of knowledge about
            vision health disparities already characterized by NEI in the
            African-American and Hispanic populations.
      vision impairment/eye disease is a major public health problem that
       increases healthcare costs, reduces productivity, and diminishes
                                quality of life
        The NEI estimates that more than 38 million Americans age 40 and
    older experience blindness, low vision, or an age-related eye disease
    such as AMD, glaucoma, diabetic retinopathy, or cataracts. This is
    expected to grow to more than 50 million Americans by year 2020. The
    economic and societal impact of eye disease is increasing not only due
    to the aging population, but to its disproportionate incidence in
    minority populations and as a co-morbid condition of chronic disease,
    such as diabetes.
        Although the NEI estimates that the current annual cost of vision
    impairment and eye disease to the United States is $68 billion, this
    number does not fully quantify the impact of direct healthcare costs,
    lost productivity, reduced independence, diminished quality of life,
    increased depression, and accelerated mortality. The continuum of
    vision loss presents a major public health problem and financial
    challenge to the public and private sectors.
        In public opinion polls over the past 40 years, Americans have
    consistently identified fear of vision loss as second only to fear of
    cancer. As recently as March 2008, the NEI's Survey of Public
    Knowledge, Attitudes, and Practices Related to Eye Health and Disease
    reported that 71 percent of respondents indicated that a loss of their
    eyesight would rate as a ``10'' on a scale of 1 to 10, meaning that it
    would have the greatest impact on their day-to-day life.
        In 2009, the NEI will celebrate its 40th anniversary as the NIH
    Institute that leads the Nation's commitment to save and restore
    vision. During the next decade, more than half of the 78 million baby
    boomers will celebrate their 65th birthday and be at greatest risk for
    developing aging eye disease. As a result, sustained, adequate Federal
    funding for the NEI is an especially vital investment in the health,
    and vision health, of our Nation as the treatments and therapies
    emerging from research can preserve and restore vision. Adequately
    funding the NEI can also delay, save, and prevent health expenditures,
    especially those associated with the Medicare and Medicaid programs,
    and is, therefore, a cost-effective investment.
        NAEVR urges fiscal year 2010 NIH and NEI funding at $32.4 billion
    and $736 million, respectively, reflecting an at least 7 percent
    increase more than fiscal year 2009.
                                     ______

      Prepared Statement of the National Association of State Alcohol and
                              Drug Abuse Directors

        Chairman Harkin, Ranking Member Cochran, members of the
    subcommittee, on behalf of the National Association of State Alcohol
    and Drug Abuse Directors (NASADAD), and our component organizations,
    the National Prevention Network, and the National Treatment Network,
    thank you for your leadership on issues related to addiction. I am Flo
    Stein, NASADAD President and member from North Carolina. I am pleased
    to present testimony regarding fiscal year 2010 funding priorities.
        Scope of the Problem.--According to the Substance Abuse and Mental
    Health Services Administration's (SAMHSA) National Survey on Drug Use
    and Health (NSDUH), approximately 23.2 million Americans aged 12 or
    older needed services for an alcohol or illicit drug problem in 2007.
    During the same year, approximately 2.4 million received treatment for
    such a problem at a specialty facility. As a result, approximately 20.8
    million people needed but did not receive services in 2007 in a
    specialty facility.
        Substance Abuse Spending Represents a Tiny Fraction of all Health
    Expenditures.--Substance abuse expenditures represented 1.3 percent of
    all healthcare expenditures in 2003 ($21 billion for substance abuse
    compared to $1,614 billion for all health expenditures). Using
    inflation adjusted terms, the growth rate for all health spending from
    1993 to 2003 was 4.6 percent, while the growth rate for substance abuse
    spending during this same time period was 1.4 percent.
        Yet Addiction is Associated With Many Other Diseases.--In a 2004
    study appearing in the Journal of the American Medical Association
    (JAMA), researchers examined ``actual causes of death'' defined by the
    Centers for Disease Control and Prevention (CDC) as factors that
    contribute to leading killers such as heart disease, cancer and stroke.
    The study identified nine leading ``actual causes of death.'' Tobacco,
    alcohol and illicit drugs--killing 530,000 Americans in 2000--were 3 of
    the top 9. The others were diet/weight; microbial agents; toxic agents;
    motor vehicles; firearms and sexual behaviors.
        Unaddressed Substance Abuse Problems are Costly.--As noted in
    SAMHSA's National Expenditures for Mental Health Services and Substance
    Abuse Treatment, 1993-2003 (2007), when substance abuse spending was
    $15.5 billion in 1998, the total economic costs of alcohol abuse were
    approximately $184.6 billion and the total economic costs for drug
    abuse were $143.4 billion (Harwood, 2000). These costs were linked not
    only to medical consequences of alcohol/drug use, but also crime, lost
    earnings, motor vehicle crashes, and more.
        Financial Investments in Addiction Services Save Taxpayer
    Dollars.--The National Institute on Drug Abuse (NIDA) notes that for
    every $1 spent on addiction treatment programs, there is an estimated
    $4 to $7 reduction in the cost of drug-related crimes. With some
    outpatient programs, total savings can exceed costs by a ratio of 12:1
    (NIDA InfoFacts, 2006).
        Maintain SAMHSA as Strong Agency.--NASADAD supports action to
    ensure that SAMHSA remains a unique, strong and vibrant agency. SAMHSA
    has demonstrated excellent leadership and collaboration--promoting
    innovative strategies to improve our service delivery system. NASADAD
    thanks Dr. Eric Broderick, Acting Administrator of SAMHSA, for his
    work. SAMHSA is to be commended and should be considered a vital voice
    in discussions related to health reform.
        Top Priority for Fiscal Year 2010--Increase Funding for Substance
    Abuse Prevention and Treatment (SAPT) Block Grant.--NASADAD recommends
    $1,928.6 million for the SAPT Block Grant in fiscal year 2010--an
    increase of $150 million more than fiscal year 2009 and more than the
    President's request. Since 2007, as the economy and State budgets
    struggled, unemployment grew by 5.5 million. This is critical news for
    the SAPT Block Grant given that the NSDUH found unemployed persons need
    services at almost twice the rate as those with jobs. An increase in
    SAPT Block Grant funds would help our public treatment system to better
    serve this increased need on the part of the low-income and uninsured
    population.
        Background.--The SAPT Block Grant, a program distributed by formula
    to all States and territories, serves our Nation's most vulnerable,
    low-income populations: those with HIV/AIDS, pregnant and parenting
    women, youth, and others. This vital program helps States and
    communities address their own unique needs--whether the problem is
    alcohol, methamphetamine, and prescription drug abuse or persons using
    multiples substances. The SAPT Block Grant represents approximately 40
    percent of treatment expenditures by State substance abuse agencies
    across the country.
        SAPT Block Grant Funded Services Achieve Results.--The SAPT Block
    Grant is an effective and efficient program that emphasizes
    accountability through the reporting of outcomes data. In particular,
    States have worked diligently with SAMHSA to implement the National
    Outcome Measures (NOMs) initiative. The SAMHSA/State partnership on
    NOMs promotes continuous quality improvement through a more systematic
    approach to data management and reporting. States now measure the
    impact of services on the use of alcohol and other drug use;
    employment; having stable housing; involvement with criminal activity;
    and efforts to live productively in the community. As noted by SAMHSA
    in 2008, SAPT Block Grant funded programs had positive results, where
    ``. . . at discharge, clients have demonstrated high abstinence rates
    from both illegal drug (68.3 percent) and alcohol (73.7 percent) use.''
        In my own State of North Carolina, our Division of Mental Health,
    Developmental Disabilities and Substance Abuse Services reported 21,102
    to treatment admissions in State fiscal year 2006/2007. In State fiscal
    year 2006/2007, North Carolina showed the following client outcomes at
    discharge: 82 percent were abstinent from alcohol use; 74 percent were
    abstinent from drug use; and 77 percent were involved in social support
    groups.
        Important Prevention Funding Within SAPT Block Grant.--Twenty
    percent of the SAPT Block Grant is dedicated to funding much needed
    substance abuse prevention programming. In many States set-aside
    funding represents a large source of prevention funds for the agency.
    Overall, SAPT Block Grant funding represents 64 percent of State
    substance abuse agency prevention funding. In 21 States, the set-aside
    represents 75 percent or more of the agency's prevention budget.
        The prevention set-aside has also helped produce demonstrable
    results. The Monitoring the Future (MTF) Survey found a 25 percent
    decline in any illicit drug use in the past month by 8th, 10th, and
    12th graders combined between 2001 and 2008. As a result, there were
    840,000 fewer teens using drugs in 2008 compared to 2001. A strong
    commitment to the SAPT Block Grant will ensure a strong commitment to
    much needed prevention services for our youth.
        Recent History of SAPT Block Grant Funding.--NASADAD is thankful
    for the increase of $19.9 million for the SAPT Block Grant in fiscal
    year 2009. However, the program has suffered over the past few years:
    from fiscal year 2004 to fiscal year 2008, funding was cut by more than
    $20 million. In fact, it is estimated that the 2010 SAPT Block Grant
    appropriation would have to be increased by $403.7 million above the
    2009 appropriation to maintain services at 2004 levels using the CPI-U
    as the proxy (Data courtesy of the New York State Office of Alcoholism
    and Substance Abuse Services (OASAS)]). As a result, NASADAD and others
    view an increase of $150 million as a down payment to make up for lost
    ground.
        Center for Substance Abuse Treatment (CSAT).--NASADAD recommends
    $489.3 million in fiscal year 2010--an increase of $75 million compared
    to fiscal year 2009 and an increase of $29.3 million compared to the
    President's request. NASADAD acknowledges Dr. H. Westley Clark,
    Director of CSAT, for his excellent leadership.
        NASADAD is thankful for the President's proposed $45.7 million
    increase for CSAT in fiscal year 2010. NASADAD is also thankful for an
    increase of $14.5 million for CSAT in fiscal year 2009. This increase
    reversed the previous administration's proposal to cut CSAT by $63
    million. The fiscal year 2009 omnibus bill restored all or a portion of
    a number of NASADAD priority programs that were set to be eliminated.
        Center for Substance Abuse Prevention (CSAP).--NASADAD recommends
    $276.3 million--an increase of $75 million compared to fiscal year 2009
    and an increase of $77.7 million compared to the President's fiscal
    year 2010 request. NASADAD applauds the work of Fran Harding, Director
    of CSAP, for her work and dedication.
        NASADAD appreciates the $6.8 million increase for CSAP in fiscal
    year 2009. Approving the fiscal year 2009 omnibus package restored
    funding for CSAP programs which were slated to be eliminated or reduced
    by the previous administration.
        Safe and Drug Free Schools and Communities--State Grants.--NASADAD
    is extremely concerned with the President's proposal to eliminate or
    zero out the Safe and Drug Free Schools and Communities (SDFSC)--State
    Grants portion in fiscal year 2010.
        NASADAD believes that the SDFSC State Grants program is an
    effective initiative that represents a core component of each State's
    substance abuse prevention system. The efficiency of the program can in
    part be attributed to principles of effectiveness that each grantee
    follows. These principles include (1) an assessment of the problem; (2)
    development of measurable goals and objectives; (3) implementation of
    effective programs and (4) assessment of program outcomes.
        We believe the program also benefits from close collaboration with
    NASADAD members. In particular, certain Governors choose NASADAD
    members as the designee to manage these important funds. This
    designation allows for a more comprehensive and coordinated approach to
    planning and implementing an effective State-wide system of care.
        NASADAD recommends $346.5 million, representing a $51.8 million
    increase more than fiscal year 2009 and representing a $346.5 million
    increase more than the President's fiscal year 2010 request for the
    program.
        National Institute on Drug Abuse (NIDA).--NASADAD recommends
    $1,105.1 million for NIDA, representing a $59.3 million increase
    compared to the President's fiscal year 2010 request and a $72.3
    million increase compared to fiscal year 2009. NASADAD wishes to thank
    Dr. Nora Volkow, Director of NIDA, for her collaboration with State
    substance abuse agencies through its ``Blending Initiative.'' This work
    improves the translation of research into everyday practice.
        National Institute on Alcohol Abuse and Alcoholism (NIAAA).--
    NASADAD recommends $481.7 million for NIAAA, which represents a $26.6
    million increase compared to the President's fiscal year 2010 request
    and a $31.5 million increase compared to fiscal year 2009.
                                     ______

      Prepared Statement of the National Association for State Community
                               Services Programs
        The National Association for State Community Services Programs
    (NASCSP), the national association representing State administrators of
    the Department of Health and Human Services' Community Services Block
    Grant (CSBG) and State directors of the Department of Energy's Low-
    Income Weatherization Assistance Program, would like to thank Congress
    for its continued support of the CSBG and requests an appropriation of
    $800 million for fiscal year 2010. We are requesting $800 million in
    CSBG funding for fiscal year 2010 to ensure the CSBG Network has
    adequate resources to sustain its expanded efforts to address the long-
    term needs of those families affected by the current economic recession
    and those transitioning from welfare to work. In addition, increased
    funding would enable the network to continue and strengthen its efforts
    to assist low-income workers in remaining at work through supportive
    services such as transportation and child care. The across the board
    cuts to the CSBG funding in past years have severely decreased the
    ability of the CSBG Network to provide and enhance essential services
    to low-income Americans. It is essential that the CSBG funding be
    increased for fiscal year 2010.
                                   background
        The States believe the CSBG is a unique block grant that has
    successfully transferred decisionmaking to the local level. Federally
    funded with oversight at the State level, the CSBG has maintained a
    local network of nearly 1,100 agencies which operate in 99 percent of
    counties in the Nation. This network serves nearly 16.2 million low-
    income individuals, members of more than 6.4 million low-income
    families, CSBG eligible entities, largely local Community Action
    Agencies (CAAs), provide States with a stable and guaranteed network of
    designated entities which are mandated to change the conditions that
    perpetuate poverty for individuals, families, and communities. There is
    no other program in the United States mandated by Federal statute to
    respond to poverty. To fulfill that mandate, CAAs provide services
    based on the characteristics of poverty in their communities. For one
    community, this might mean providing job placement and retention
    services; for another, developing affordable housing. In rural areas,
    it might mean providing access to health services or developing a rural
    transportation system.
        Since its inception, the CSBG has shown how partnerships between
    States and local agencies benefit citizens in each State. We believe it
    should be viewed as a model of how the Federal Government can best
    promote self-sufficiency for low-income persons in a flexible,
    decentralized, nonbureaucratic, and accountable way.
        Long before the creation of the Temporary Assistance for Needy
    Families (TANF) block grant, the CSBG set the standard for private-
    public partnerships that work to revitalize local communities and
    address the needs of low-income residents. Family oriented, while
    promoting economic development and individual self-sufficiency, the
    CSBG relies on an existing and experienced community-based service
    delivery system of CAAs and other nonprofit organizations to produce
    results for its clients.
                        what do local csbg agencies do?
        One thing that is common to all CAAs is the goal of self-
    sufficiency for all of their clients. But, since CAAs operate in rural
    areas as well as in urban areas, it is difficult to describe a typical
    CAA. Most CAAs will provide some, if not all, of the services listed
    below:
      --a variety of crisis and emergency safety net services;
      --employment and training programs;
      --transportation and child care for low-income workers;
      --individual development accounts;
      --micro business development help for low-income entrepreneurs;
      --local community and economic development projects;
      --housing, transitional housing, and weatherization services;
      --Head Start;
      --energy assistance programs;
      --nutrition programs;
      --family development programs; and
      --senior services.
        CSBG is the core funding which holds together a local delivery
    system able to respond effectively and efficiently, without a lot of
    red tape, to the needs of individual low-income households as well as
    to broader community needs. In addition, CSBG funds many of these
    services directly. Without the CSBG, local agencies would not have the
    capacity to work in their communities developing local funding, private
    donations and volunteer services and running programs of far greater
    size and value than the actual CSBG dollars they receive.
        CAAs manage a host of other Federal, State, and local programs
    which makes it possible to provide a one-stop location for persons
    whose problems are usually multi-faceted. More than half (52 percent)
    of the CAAs manage the Head Start program in their community. Using
    their unique position in the community, CAAs recruit additional
    volunteers, bring in local school district personnel, tap into faith-
    based organizations for additional help, coordinate child care and
    bring needed healthcare services to Head Start centers. In many States
    they also manage the Low Income Home Energy Assistance Program
    (LIHEAP), raising additional funds from utilities for this vital
    program. CAAs may also administer the Weatherization Assistance Program
    and are able to mobilize funds for additional work on residences not
    directly related to energy savings that, for example, may keep a low-
    income elderly couple in their home. CAAs also coordinate their
    programs with the Community Development Block Grant program to stretch
    Federal dollars and provide a greater return for tax dollars invested.
    They also administer the Women, Infants and Children nutrition program,
    as well as job training programs, substance abuse programs,
    transportation programs, domestic violence and homeless shelters, and
    food pantries.
        For every CSBG dollar they receive, CAAs leverage $5.59 in non-
    Federal resources (State, local, and private) to coordinate efforts
    that improve the self-sufficiency of low-income persons and lead to the
    development of thriving communities.
                            who does the csbg serve?
        National data compiled by NASCSP show that the CSBG serves a broad
    spectrum of low-income persons, particularly those who are not being
    reached by other programs and are not being served by welfare programs.
    Based on the most recently reported data, from fiscal year 2007 CSBG
    serves:
      --More than 3 million families with incomes at or below the poverty
            level; of these customer families, 1.4 million are severely
            poor as they have incomes at or below 50 percent of the poverty
            guideline.
      --More than 1.3 million families headed by single mothers.
      --More than 1.7 million ``working poor'' families relying on wages or
            unemployment benefits as income.
      --More than 384,000 TANF participant families, 23 percent of all TANF
            families nationwide.
      --About 4 million children.
      --Almost 2.7 million people without health insurance.
      --More than 1.7 million adults who had not completed high school.
                   major characteristics of the csbg network
        Due to the unique structure of the CSBG, the CSBG Network has
    earned a reputation for its:
        Emergency Response.--CAAs are utilized by Federal and State
    emergency personnel as a frontline resource to deal with emergency
    situations such as floods, hurricanes, and economic downturns. They are
    also relied on by citizens in their community to deal with individual
    family hardships, such as house fires or other emergencies. In fact,
    during and after Hurricanes Katrina and Rita, the State CSBG offices
    and local CAAs quickly mobilized to provide immediate and long-term
    assistance to evacuees.
        Leveraging Capacity.--In fiscal year 2007, every CSBG dollar
    leveraged $18.40 from all other sources. Of those leveraged funds,
    $5.59 came from non-Federal resources (State, local, and private) to
    coordinate efforts that improve the self-sufficiency of low-income
    persons and lead to the development of thriving communities.
        Volunteer Mobilization.--CAAs mobilize volunteers in large numbers.
    In fiscal year 2006, the most recent year for which data are available,
    the CAAs elicited more than 46 million hours of volunteer efforts, the
    equivalent of almost 21,857 full-time employees. Using just the minimum
    wage, these volunteer hours are valued at nearly $266 million.
        Adaptability.--CAAs provide a flexible local presence that
    governors have mobilized to deal with emerging poverty issues.
        Moreover, the CSBG Network has also earned a reputation for its:
        Accountability.--The Federal Office of Community Services, State
    CSBG offices, and CAAs have worked closely to develop a results-
    oriented management and accountability (ROMA) system. Through this
    system, individual agencies determine local priorities within six
    common national goals for CSBG and report on the outcomes that they
    achieved in their communities.
        Local Direction and Oversight.--Tri-partite boards of directors
    guide CAAs. These boards consist of one-third elected officials, one-
    third representatives from the private sector, and not less than one-
    third of the members are representative of the low-income persons in
    the neighborhoods served by the CAA. The boards are responsible for
    establishing policy and approving business plans of the local agencies.
    Since these boards represent a cross-section of the local community,
    they guarantee that CAAs will be responsive to the needs of their
    community.
        The statutory goal of the CSBG is to ameliorate the effects of
    poverty. The primary goal of every CAA is self-sufficiency for its
    clients. Helping families become self-sufficient is a long-term process
    that requires multiple resources. This is why the partnership of
    Federal, State, local, and private enterprise has been so vital to the
    successes of the CAAs.
                            examples of csbg at work
        Since 1994, CSBG has implemented a Results-Oriented Management and
    Accountability (ROMA) system. Through ROMA, the effectiveness of
    programs is captured through the use of goals and outcomes measures.
    Below you will find several of the network's nationally aggregated
    outcomes achieved by individuals, families and communities as a result
    of their participation in innovative CSBG programs during fiscal year
    2007:
      --Increased Economic Asset Enhancement and Utilization.--694,000 low-
            income households achieved an increase in financial assets or
            financial skills as a result of Community Action assistance.
      --Procured Supports To Reduce or Eliminate Barriers to Employment.--
            1.3 million low-income participants obtained supports which
            reduced or eliminated barriers to initial or continuous
            employment through assistance from Community Action.
      --Gained Employment.--193,000 low-income participants in Community
            Action employment initiatives got a job, obtained an increase
            in employment income, or achieved ``living wage'' employment
            and benefits.
      --Improved Child and Family Development.--2.9 million Infants,
            children, youth, parents, and other adults participated in
            developmental or enrichment programs facilitated by Community
            Action and achieved program goals.
      --Secured Independent Living for Low-Income Vulnerable Populations.--
            2 million low-income vulnerable individuals received services
            from Community Action and maintained an independent living
            situation as a result.
        At the end of the day, the CSBG Network represents our abiding
    national commitment to care for the less fortunate and in recognition
    that we are stronger when we do so. The CSBG and CSBG Network, in
    addition to other nonprofit faith-based and community-based
    organizations, are a critical complement to the public sector's efforts
    towards helping to lift low-income Americans and their communities out
    of poverty and into self-sufficiency.
        In fiscal year 2007, the CSBG Network assisted approximately 20
    percent of the persons in poverty that year and almost 15 million low-
    income individuals who are members of more than 6.4 million low-income
    families. Renewed funding for the CSBG Network is one of the best ways
    to ensure that America has an experienced, guaranteed and trusted
    network to assist its working and vulnerable families in achieving and
    maintaining self-sufficiency. As such, NASCSP requests $800 million in
    CSBG funding for fiscal year 2010.
                                     ______

     Prepared Statement of the National Association of State Directors of
                     Career Technical Education Consortium
                         department of education budget
        In his budget submission to Congress, President Obama has requested
    flat funding for programs funded under the Carl D. Perkins Career
    Technical Education (CTE) Act. If this level of funding holds, this
    will be the third year in a row these programs will have received flat
    funding. These programs are worthy of stronger support because of the
    valuable contributions they make to serving adults and high school
    students in their journey for education and training and eventual entry
    into the workforce. Perkins CTE programs:
      --Provide education that is relevant to students;
      --Are actively reforming high school curriculum;
      --Provide coordination between high schools and community colleges;
            and
      --Prepare workers for jobs that are in demand.
        We respectfully request that the subcommittee include $1.4 billion
    in support of Perkins programs. The last substantial funding increase
    for Perkins occurred in fiscal year 2002. Since that time funding has
    decreased by $42 million. When factoring in inflation this is the
    equivalent of a reduction of $254 million.
        Perkins includes a ``hold harmless'' provision that protects small
    States from significant losses when there are reductions in Tech Prep
    (title II of Perkins) funding. However, this provision only applies as
    long as the total funding for Tech Prep does not fall below 1998
    levels. Unfortunately, during the fiscal year 2008 appropriations
    cycle, Tech Prep funding fell below this level and in turn, the hold
    harmless provision put in place to protect small States was de-
    activated. While most States have taken a loss of Tech Prep funds, the
    small States have felt this cut in funding disproportionately. These
    States have seen their Tech Prep funds reduced between 7 and 56 percent
    below their fiscal year 2007 levels, costing some States hundreds of
    thousands of dollars over the last 2 years. Below is a chart that
    details the States and the approximate amount of funds they have lost
    over the last 2 years. The funding figures are approximated because
    only tentative fiscal year 2009 allocation numbers are available.

    ------------------------------------------------------------------------
                              State                               Amount
    ------------------------------------------------------------------------
    Alaska..................................................        $221,390
    Delaware................................................         426,666
    District of Columbia....................................         349,264
    Hawaii..................................................         224,508
    Montana.................................................         144,226
    Nevada..................................................         279,600
    New Hampshire...........................................         295,212
    North Dakota............................................          50,758
    Rhode Island............................................         370,442
    South Dakota............................................          92,616
    Vermont.................................................         209,334
    Wyoming.................................................          86,416
    ------------------------------------------------------------------------

        Tech Prep funding for the last 2 years was less than $100,000 below
    the fiscal year 1998 hold harmless level of $103 million. If funding
    for Tech Prep is raised ever so slightly to $103 million these States
    will not be so negatively impacted.
    Why Career Technical Education?
        Career technical education (CTE) provides students and adults with
    the academic and technical skills, knowledge and training necessary to
    succeed in future careers and develop skills they will use throughout
    their careers. CTE programs have been organized into 16 career
    clusters, or similar occupational groupings, that identify the
    knowledge and skills students need as they follow a pathway to their
    goals. These clusters are: Agriculture, Food, and Natural Resources;
    Architecture and Construction; Arts, A/V Technology and Communications;
    Business Management and Administration; Education and Training;
    Finance; Government and Public Administration; Health Science;
    Hospitality and Tourism; Human Services; Information Technology; Law,
    Public Safety, Corrections, and Security; Manufacturing; Marketing;
    Science, Technology, Engineering and Mathematics; and Transportation,
    Distribution and Logistics.
        CTE prepares students for the world of work by introducing them to
    workplace competencies, and makes academic content accessible to
    students by providing it in a hands-on context.
        CTE programs can be found in comprehensive high schools with career
    technical education programs, as well as high schools solely devoted to
    career technical education. Community colleges, technical institutes,
    and skill centers also offer career technical education at the
    postsecondary level. Nationally, about 60 percent of Perkins funds are
    allocated for secondary school purposes and 40 percent for
    postsecondary programs.
    Programs of Study
        The Carl D. Perkins Career and Technical Education Act of 2006
    (Public Law 109-270), which funds CTE programs, requires States to
    develop programs of study to guide students when choosing courses.
    These programs of study include career and technical areas that:
      --Incorporate both secondary and postsecondary education elements;
      --Include rigorous content, challenging academic standards, and
            relevant career and technical content in a coordinated,
            nonduplicative series of courses that align secondary and
            postsecondary education;
      --May allow high school students to participate in dual or concurrent
            enrollment programs or otherwise acquire postsecondary credit;
            and
      --Result in an industry-recognized credential or certificate, or
            associate or baccalaureate degree.
    Tech Prep
        Tech Prep is a program in the Perkins Act that links a minimum of 2
    years of secondary school and 2 years of post-secondary school or an
    apprenticeship program, resulting in an associate degree or
    certificate. Tech Prep allows students to begin a sequence of classes
    in a career pathway while still in high school. Students enroll in both
    academic and career and technical classes in the career field of their
    choosing in order to develop the technical skills necessary for future
    employment.
    The Benefits of CTE
                Academic
      --Students enrolled in CTE programs are held to the same rigorous
            academic standards as all students;
      --CTE provides a strong foundation for those pursuing a traditional
            4-year degree; and
      --CTE students are more interested and motivated in their coursework
            because of its connection to the real world, and have lower
            dropout rates than traditional students.
                Economic
      --Many sectors of the economy that require skilled workers report a
            shortage of qualified applicants to fill these positions. CTE
            programs prepare individuals for skilled professions that are
            essential to our Nation's economic recovery.
      --CTE programs prepare students, adults, and displaced workers for
            entry into high-skill, high-wage, and high-demand careers in
            every industry sector.
        The Federal role in ``vocational'' education began as a way to
    prepare students for the newly industrialized economy. Over the years,
    the program has evolved to match the needs of the changing economy,
    focusing on postsecondary as well as secondary education while giving
    students skills they can use throughout their careers.
        In 2006, the language ``vocational and technical'' was updated to
    ``career and technical'' education. This transition was more than just
    a name change. It represented a fundamental shift in philosophy from
    CTE being for those who were not going to college to a system that
    prepares students for both employment and postsecondary education. The
    integration of academic and technical education programs was
    strengthened, further emphasizing the goal of ensuring that students
    who participate in CTE are taught the same rigorous content aligned
    with challenging academic standards as all other students. With all
    school programs now adhering to the same academic standards, the
    separate ``track'' system that has stigmatized CTE is disappearing. The
    chart that follows summarizes these changes.

    ------------------------------------------------------------------------
                                                  New career and technical
         Traditional vocational education                 education
    ------------------------------------------------------------------------
    For specific students                       For all students
    ------------------------------------------------------------------------
    Limited program areas offered               16 Career Clusters and 79
                                                 pathways offered
    Separate ``track'' with a focus on          Integrated with academics in
     technical education                         a rigorous and relevant
                                                 curriculum
    ------------------------------------------------------------------------
    High school focused                         High school and
                                                 postsecondary partnerships
                                                 providing pathways to
                                                 employment and/or
                                                 associate, bachelor's, and
                                                 advanced degrees
    ------------------------------------------------------------------------
    Students trained with focus on specific     Progression of foundational,
     occupational skill set                      pathway, occupational, and
                                                 21st century skills
    ------------------------------------------------------------------------

        Career technical education programs have changed with the times and
    are a fundamental piece of the education and training available to
    Americans so that they can get the skills they need in today's economy.
    Today, there are more than 15 million students and displaced workers
    enrolled in CTE programs all across America. An increase in funding
    would enable CTE programs to produce more skilled workers to fill the
    jobs that are crucial to America's economy. Funds for these programs
    will help high schools that are reeling from State and local budget
    reductions and help community colleges accommodate their increasing
    enrollments. We hope that you can provide $1.4 billion for Perkins CTE
    supported programs in the fiscal year 2010 budget.
                                     ______

     Prepared Statement of the National Alliance of State and Territorial
                                 AIDS Directors
        The National Alliance of State and Territorial AIDS Directors
    (NASTAD) represents the Nation's chief State health agency staff who
    have programmatic responsibility for administering HIV/AIDS and viral
    hepatitis healthcare, prevention, education, and supportive service
    programs funded by State and Federal Governments.
        As you craft the fiscal year 2010 Labor, Health and Human Services,
    and Education, an Related Agencies appropriations legislation, we urge
    you to consider the following critical funding needs of HIV/AIDS, viral
    hepatitis, and sexually transmitted diseases (STD) programs:
      --$1.6 billion for the Ryan White Part B Program, including $514
            million for the Part B Base and $1.1 billion for the AIDS Drug
            Assistance Program (ADAP);
      --$1.6 billion for the Centers for Disease Control and Prevention's
            (CDC) HIV/AIDS Prevention Program, including an additional $249
            million for State and local health department prevention
            cooperative agreements to include an additional $49 million for
            State and local HIV/AIDS surveillance systems, and the
            expansion of the domestic HIV/AIDS Testing Initiative to
            additional populations and jurisdictions;
      --$50 million for CDC's Viral Hepatitis Prevention Program, including
            a doubling of resources for the Adult Viral Hepatitis
            Prevention Coordinator Program to $10 million.
      --$16 million for hepatitis B vaccination for high-risk adults
            through the Section 317 Vaccine Program;
      --$451 million for CDC's STD Prevention Program for prevention,
            treatment and surveillance cooperative agreements with State
            and local health departments; and
      --$610 million for the Minority AIDS Initiative to enhance capacity
            in communities of color.
    HIV/AIDS Care and Treatment Programs
        The Health Resources and Services Administration administers the
    $2.2 billion Ryan White Program that providing health and support
    services to more than 500,000 HIV-positive individuals. NASTAD
    respectfully requests a minimum increase of $362 million in fiscal year
    2010 for State Ryan White Part B grants, including an increase of at
    least $113 million for the Part B Base and at least $269 million for
    ADAPs. With these funds all States and territories provide care,
    treatment, and support services to persons living with HIV/AIDS. People
    living with HIV need access to trained HIV clinicians, life-saving and
    life-extending therapies, and a full range of support services to live
    as healthy a life as possible and to ensure adherence to complicated
    treatment regimens. All States are reporting to NASTAD that they are
    seeing a significant increase in the number of individuals seeking Part
    B Base and ADAP services--for some States it's a doubling of new
    clients per month from the previous year. This is due to a number of
    factors including, increased testing efforts and unemployment.
        Ryan White Part B Base programs include ambulatory medical
    services, case management, laboratory services, and an array of support
    services. As of October 10, 2008, four States report that 266
    individuals are on either a medical or support service waiting list for
    services that include housing, mental health counseling, specialty
    medical care, and transportation. Five States report that funding is
    insufficient to ensure that all eligible patients attend medical
    appointments every 3 months, which is the standard of care. Eight part
    B programs are also considering cost containment measures for their
    part B services in light of high demand and reduced funding.
        State ADAPs provide medications to low-income individuals with HIV
    disease who have limited or no coverage from private insurance or
    Medicaid. While only three States currently have a waiting list with 53
    individuals, the present fiscal condition of State ADAPs remain
    fragile. In fiscal year 2008, State ADAPs were relatively stable due to
    increased State contributions, increased rebates from drug companies,
    $39.7 million in ADAP Supplemental grants, transfers of Part B Base
    funding into ADAP, and program savings from the Medicare Part D
    Prescription Drug Benefit. The continuing increase in clients and the
    cuts in State contributions to ADAP (one State has cut their ADAP
    contribution by $70 million) render the fiscal future of ADAPs
    uncertain. On average, State spending accounts for 21 percent of the
    total ADAP budget. Additionally, CDC estimates that their on-going
    Domestic HIV/AIDS Testing Initiative will find 20,000 new infections
    over the next year.
        While we are very supportive of the funding increases in recent
    years for the community health center (CHC) program, we want to be
    clear that this hasn't necessarily translated into more care for person
    living with HIV/AIDS. CHCs focus on primary care with most of the HIV/
    AIDS care being provided in centers with Ryan White Part C grants.
    HIV/AIDS Prevention and Surveillance Programs
        At the request of Congress, the CDC developed a Professional
    Judgment Budget detailing the needed resources to significantly reduce
    the number of Americans becoming infected with HIV each year. CDC
    identified the need for a funding increase of $878 million for total
    funding of $1.6 billion for CDC's HIV prevention program in fiscal year
    2010. As Congress strives to reach the $1.6 billion overall investment
    in HIV prevention, NASTAD respectfully requests an initial increase of
    $249 million in State and local health department HIV prevention and
    surveillance cooperative agreements. This would include an additional
    $49 million for State and local HIV/AIDS surveillance systems and the
    expansion of the Domestic HIV/AIDS Testing Initiative to additional
    populations and jurisdictions.
        An estimated 56,300 new infections occur every year while State and
    local HIV prevention cooperative agreements have been cut by $21
    million between fiscal year 2003 and fiscal year 2008. CDC's 2007
    surveillance reports showed a 15 percent increase in HIV diagnoses in
    the 34 States included in the national database while CDC's HIV
    prevention funding was cut in fiscal year 2008 and flat-funded in
    fiscal year 2009. Additionally, core HIV/AIDS surveillance funding has
    eroded over the last decade, while the importance of this data has
    become paramount for targeting prevention efforts and directing Ryan
    White resources.
        The Nation's prevention efforts must match our commitment to the
    care and treatment of infected individuals. State and local public
    health departments know what to do to prevent new infections, they just
    need the resources. First and foremost we must address the devastating
    impact on racial and ethnic minority communities. We must expand
    outreach and HIV testing efforts targeting high-risk populations
    including gay and bisexual men of all races, racial, and ethnic
    minority communities, substance users, women, and youth. But, testing
    alone can never end the epidemic. All tools in the prevention arsenal
    must be supported. Additional resources must be directed to build
    capacity and provide technical assistance to enable community-based
    organizations and healthcare providers to implement evidence-based
    behavior change interventions, ensure fiscal responsibility and refer
    partners of HIV-positive individuals to counseling and testing
    services.
        The Domestic HIV/AIDS Testing Initiative is an important step to
    increasing knowledge of serostatus, particularly among African
    Americans. Currently 25 jurisdictions (20 States and five cities)
    receive $36 million for the Expanded Testing Initiative (ETI),
    including rapid testing, in clinical settings such as emergency rooms,
    community health centers, correctional health facilities, and STD and
    tuberculosis clinics. Both CDC and NASTAD conducted assessments of year
    1 including progress and challenges faced. Following significant scale-
    up efforts in all jurisdictions, 21 of the funded jurisdictions
    conducted 446,503 tests in year 1 of the ETI. Nearly 4,000 new HIV
    infections were identified, 80 percent of which were in clinical
    settings. During the first year, 86 percent of testing occurred in
    clinical settings. Of the total number of tests conducted in the first
    year, 64 percent were administered to African Americans. Seventy
    percent of the newly identified infections were among African
    Americans.
        We are requesting that CDC receive sufficient resources to expand
    the number of jurisdictions participating in the initiative--all
    jurisdictions have a need for increased resources for testing if we are
    to truly commit to providing access to testing for all individuals who
    do not yet know their HIV status. Additional funding would also allow
    the targeting of additional populations such as gay and bisexual men of
    all races and Latinos. Another key component of the initiative to
    expand is identification, notification and counseling of partners of
    persons living with HIV/AIDS. Partner services are time and resource
    intensive but maximize prevention efforts.
        With 21 percent of HIV-infected persons unaware that they have HIV,
    increased funding for testing and partner services will avert millions
    in unnecessary healthcare costs.
        We urge the subcommittee to not include language banning use of
    Federal funds for syringe exchange programs in the fiscal year 2010
    Labor, Health and Human Services, and Education, an Related Agencies
    appropriations bill. Abundant research, endorsed by the findings of
    eight federally commissioned reviews, has conclusively demonstrated
    that syringe exchange is effective in reducing the transmission of HIV
    without increasing drug use. In communities that fund and support
    access to sterile injection equipment using State and local funds,
    transmission of HIV and hepatitis in persons who inject drugs has
    declined as a proportion of all cases by mode of transmission.
    Unfortunately, State and locally funded syringe exchange are only
    reaching a small portion of persons who inject drugs. It's time for the
    Federal Government to use every tool at its disposal to arrest the
    further spread of HIV and hepatitis C.
        We also urge you to eliminate funds for the three separate Federal
    abstinence-only-until-marriage programs. Instead, we request that you
    create a dedicated Federal funding stream of at least $50 million in
    your 2010 budget to fund medically accurate, comprehensive sex
    education programs that teach young people about both abstinence and
    contraception.
        Lastly, we thank you and ask that you continue to limit the funding
    for the duplicative Early Diagnosis Grant Program in Section 209 of the
    Ryan White Treatment Modernization Act of 2006. This program is a carve
    out of limited HIV testing resources when there is already $10 million
    dedicated to perinatal prevention.
    Viral Hepatitis Prevention Programs
        NASTAD respectfully requests an increase of $36.4 million for a
    total of $50 million in fiscal year 2010 for the CDC's Division of
    Viral Hepatitis (DVH) to enable State and local health departments to
    provide basic core public health services. DVH currently receives $18.3
    million to address chronic viral hepatitis B and C impacting 6.2
    million Americans. This is $7 million less than its peak funding of $25
    million in fiscal year 2001. Currently CDC addresses viral hepatitis on
    outbreak at a time, which is neither cost-effective nor real
    prevention.
        Of the DVH funding, $5.2 million is used to fund the Adult Viral
    Hepatitis Coordinator Program with an average award to States of
    $90,000. Doubling this program to $10 million would allow States to
    implement a hepatitis prevention strategy. The coordinator position
    receives precious little above personnel costs, leaving little to no
    money for the provision of public health services including public
    education, hepatitis counseling, testing, and hepatitis A and B
    vaccine. In addition, there are no funds for surveillance of chronic
    viral hepatitis, which would allow States to better target their
    limited resources. Given the recent hepatitis public health crises in
    Nevada and New York, the Government has a choice--invest in prevention
    now or wait until public systems are overwhelmed by a lack of
    infrastructure to address future outbreaks.
        The greatest remaining challenge for hepatitis A and B prevention
    is the vaccination of high-risk adults. High-risk adults account for
    more than 75 percent of all new cases of hepatitis B infection each
    year and annually result in an estimated $658 million in medical costs
    and lost wages. In fiscal year 2007, CDC allowed States to use $20
    million of 317 Vaccine funds to vaccinate high-risk adults for
    hepatitis B and $16 million in fiscal year 2008. By targeting high-risk
    adults, including those with hepatitis C, for vaccination, the gap
    between children and adults who have not benefited from routine
    childhood immunization programs can be bridged. NASTAD requests a
    continuation of the $16 million in section 317 Vaccine funds in fiscal
    year 2010 for hepatitis B vaccination for high-risk adults with the
    request that in the future DVH receives dedicated funding for hepatitis
    A and B vaccine for high-risk adults and funding to support the
    infrastructure necessary for vaccine delivery.
    STD Prevention Programs
        NASTAD supports an increase of $299 million for a total of $451
    million in fiscal year 2010 for STD prevention, treatment and
    surveillance activities undertaken by State and local health
    departments. STD prevention programs at CDC have been cut by $6 million
    since fiscal year 2004 while the number of persons infected continues
    to climb. The United States has the unwanted distinction of having the
    highest rates of STDs of all industrial nations with 1 in 4 adolescent
    girls in the United States, or more than 3 million, having an STD. The
    rates of syphilis infection have increased for the seventh year in a
    row. In 1 year, our Nation spends more than $8 billion to treat the
    symptoms and consequences of STDS. Additional Federal resources are
    needed to reverse these alarming trends and reduce the Nation's health
    spending.
    Minority AIDS Initiative
        NASTAD also supports a $200 million increase for a total of $610
    million for the Minority AIDS Initiative (MAI) in fiscal year 2010. The
    MAI provides targeted resources to four agencies and the Office of the
    Secretary to address the HIV/AIDS epidemic in hard-hit communities of
    color. The data from CDC on the disproportionate impact on African
    Americans and Latinos continues to be alarming. Support for the MAI
    along with the traditional funding streams that serve these populations
    is essential.
        As you craft the fiscal year 2010 Labor, Health and Human Services,
    and Education, an Related Agencies appropriations bill, we ask that you
    consider all of these critical funding needs. National Alliance of
    State and Territorial AIDS Directors thanks the Chairman, Ranking
    Member and members of the subcommittee, for their thoughtful
    consideration of our recommendations. Our response to the HIV, viral
    hepatitis, and STD epidemics in the United States defines us as a
    society, as public health agencies, and as individuals living in this
    country. There is no time to waste in our Nation's fight against these
    infectious and often chronic diseases.
                                     ______

        Prepared Statement of the National Congress of American Indians
        On behalf of the tribal nations of the National Congress of
    American Indians (NCAI), we are pleased to present our recommendations
    for fiscal year 2010 funding of Indian programs in the Departments of
    Labor, Health and Human Services, and Education, and Related Agencies.
    President Obama released a broad budget plan for fiscal year 2010 and
    from what NCAI has reviewed of the blueprint so far, the new
    administration plans to ensure America's promise extends to the entire
    Nation, including throughout Indian country.
        After tribes witnessed years of declining resources for critical
    Indian programs in the Federal budget, the attention the
    administration's fiscal year 2010 proposed budget has given to tribal
    priorities is a welcome change. The chairman of this subcommittee has
    heard often of the social and economic challenges facing Indian
    country. This subcommittee has also heard that the recent resurgence of
    tribal self-determination has resulted in measurable improvements in
    the poverty, income, and unemployment among Indian people.
        Indian tribes are rebuilding our Nations in ways that honor our
    ancestors and cultures as well as meeting the demands and opportunities
    of living in the modern world. An analysis of socioeconomic change
    between 1990 and 2000 showed that Indian country economies grew at a
    faster pace than the economy as a whole. Although Indian tribes have
    made great strides in addressing the long-accumulated economic deficits
    in our communities, much work remains to be done. Tribes also have a
    critical role to play in the recovery as the Nation pulls out of the
    current destructive recession. As the President and Congress aim to
    invest in people to strengthen the middle class and the drivers of
    economic growth, NCAI looks forward to tribal self-determination
    playing a part in the solution. To ensure tribes continue to make
    progress, sustained investment in tribal governments and programs that
    support self-determination will be critical in fiscal year 2010. With
    the new administration and the fiscal year 2010 budget request, there
    is renewed hope in Indian country.
        The President's fiscal year 2010 budget priorities appear to align
    with many of Indian country's priorities: education, healthcare,
    infrastructure, and clean energy. Below are some budget recommendations
    for the Labor, Health and Human Services, and Education, and Related
    Agencies appropriations bill.
                    department of health and human services
        Tragically, over the last year, nearly 3,000 American Indians and
    Alaska natives died of cardiovascular disease, more than 16,500 were
    diagnosed with a sexually transmitted disease, 5,000 were diagnosed
    with diabetes for the first time, more than 22,000 are now living with
    cancer (45 percent of which were diagnosed in the late-stages), and 400
    took their own life.
        These people are our tribal leaders; our daughters and sons; our
    mothers and fathers; and, our brothers and sisters. For more than 100
    years, Native people have experienced inferior health outcomes. Our
    life expectancy is still 5 years less than that of other Americans.
    Adequate funding is needed to end this lasting injustice and uphold the
    Federal trust responsibility of the United States and the Federal
    Government.
        Provide $1 billion overall for Head Start funding. Provide $10
    million for Esther Martinez language programs under the Administration
    for Native Americans. Fifteen million dollars to fund SAMHSA Behavioral
    Health Services Grants for American Indian and Alaska Natives. Increase
    Circles of Care, SAMHSA by $5 million
                    administration for children and families
        Head Start.--Over the past 40 years, Head Start has played a major
    role in the education of Indian children and in the well-being of many
    tribal communities. However, because of inadequate funding, only about
    16 percent of the age-eligible Indian child population is enrolled in
    Indian Head Start. The comprehensive nature of this program integrates
    education, health, and family services. Since it closely mirrors a
    traditional Indian educational model, it is one of the most successful
    Federal programs operating in Indian country. Despite these successes,
    Head Start funding has declined by 14 percent over the last 6 years,
    after factoring in inflation. Head Start should be funded at a rate
    substantially greater than inflation to make up for prior year cuts and
    also to trigger special Indian expansion funds that Congress provided
    when the Head Start Act was reauthorized in 2007.
      --$1 billion--Head Start funding (overall)
                      administration for native americans
        Native Languages.--Throughout Indian country, tribes are combating
    the loss of traditional languages by advocating for and instituting
    language programs within their communities. These language programs
    serve Native communities by preventing the loss of tribal traditions
    and cultures. The tribal students in these language immersion programs
    perform substantially better academically, including on national tests,
    than Native students who have been enrolled in such programs.
      --$10 million--Esther Martinez language programs under the
            Administration for Native Americans
       substance abuse and mental health services administration (samhsa)
        American Indian and Alaska Native Grant Program.--This grant
    program within SAMHSA has been authorized to award grants to Indian
    health programs to provide the following services: prevention or
    treatment of drug use or alcohol abuse, mental health promotion, or
    treatment services for mental illness. To date, these funds have never
    been appropriated.
      --$15 million to fund SAMHSA Behavioral Health Services Grants for
            American Indian and Alaska natives.
        Circles of Care.--Increase funding to $10 million a year for the
    Circles of Care children's mental health grant program under Programs
    of National and Regional Significance under SAMHSA. This grant program
    has historically been funded at about $5 million a year, which provides
    for approximately seven tribal grants during each 3-year grant cycle.
    The program has been very successful and has spawned several new tribal
    children's mental health programs in Indian country that as a result
    have been self-sustaining.
      --Increase of $5 million
                            department of education
        The administration intends to make investments in education so all
    Americans can have the chance to receive a world-class education from
    cradle to career. The 2007 National Indian Education Study indicated
    that in reading and math, American Indian and Alaska native students
    scored significantly lower than their peers in both fourth and eighth
    grades. To ensure that Native students--from pre-school to college--
    meet the same challenging academic standards as other populations and
    experience the benefits of a quality and supportive education, it is
    imperative that the Federal Government uphold its responsibility for
    the education of Indian people.
        Provide $195.5 million for title VII funding under the No Child
    Left Behind Act. Increase Impact Aid funding 10 percent to adjust for
    inflation and population growth ($1,365 million). Provide $32 million
    for title III, Higher Education Act (HEA). Provide $62 million (one-
    time) forward funding for Tribal Colleges and Universities (TCUs).
    Provide $10 million for tribal education departments.
        Title VII Funding.--This funding provides critical support for
    culturally based education approaches for American Indian and Alaska
    native students and addresses the unique educational and cultural needs
    of Native students. It is well-documented that Native students are more
    likely to thrive in environments that support their cultural identities
    while introducing different ideas. Title VII has produced many success
    stories within our communities, but increased funding is critical in
    this area to bridge the achievement gap for Native students.
      --$195.5 million
        Impact Aid Funding.--Impact Aid provides resources to public
    schools whose tax bases are reduced because of Federal activities,
    including the presence of an Indian Reservation. Impact Aid affects
    Native children living on or near tribal lands and children of military
    families living on or near bases. Approximately 95 percent of American
    Indian and Alaska Native youth are educated in public schools. Impact
    Aid funding must be adjusted based on population increases and
    inflation.
      --Increase impact aid funding 10 percent to adjust for inflation and
            population growth ($1,365 million)
        TCUs.--Titles III and V of the HEA, known as Aid for Institutional
    Development programs, support institutions with a large proportion of
    financially disadvantaged students and low cost-per-student
    expenditures. TCUs fit this definition. The Nation's 36 TCUs serve some
    of the most impoverished areas in the Nation, yet they are the
    country's most poorly funded postsecondary institutions. Congress
    recognized the TCUs as young and struggling institutions and authorized
    a separate section of title III (part A, section 316) specifically to
    address their needs. Additionally, a separate section (section 317) was
    created to address similar needs of Alaska native and Native Hawaiian
    institutions. Section 316 is divided into two competitive grants
    programs: Formula funded basic development grants and competitive
    single-year facilities construction grants. Under the Tribal College
    Act, securing the one-time payment to transition institutional
    operating grants to a forward funded program would finally end the
    cycle of delayed payments, short-term loans, and layoffs that currently
    plague TCUs each year; and, further for the first time, it would
    provide these institutions the resources they need at the start of each
    academic year.
      --$32 million--Title III, HEA
      --$62 million (one-time) forward funding for TCUs
        Tribal Education Departments.--More than 100 Indian tribes have
    started Tribal Education Departments (TED). TEDs develop and administer
    policies, gather and report data and perform critical research to help
    tribal students from early childhood through higher and adult
    education. TEDs serve thousands of tribal students nationwide in BIA,
    tribal, and public schools. They also cultivate leadership skills and
    train a potential workforce. Funding for TEDs has been authorized by
    Congress but never appropriated in either the BIA budget or that of the
    Department of Education. Both of these authorizations are retained in
    the No Child Left Behind Act of 2001. Tribes must have access to
    funding in order to close the achievement gaps so that tribal students
    will be better equipped to perform well in school. We recommend that $5
    million of the funding be directed from the Department of the Interior
    and $5 million of the funding be directed from the Department of
    Education.
      --$10 million--Tribal education departments
                                   conclusion
        NCAI realizes Congress must make difficult budget choices this
    year. As elected officials, tribal leaders certainly understand the
    competing priorities that you must weigh over the coming months.
    However, the Federal Government's constitutional and treaty
    responsibility to address the serious needs facing Indian country are
    unique. These responsibilities remain unchanged, whatever the economic
    climate and competing priorities may be. We at NCAI urge you to make a
    strong, across-the-board commitment to meeting the Federal trust
    obligation by fully funding those programs that are vital to the
    creation of vibrant Indian nations. Such a commitment, coupled with
    continued efforts to strengthen tribal governments and to clarify the
    Government-to-government relationship, truly will make a difference in
    helping us to create stable, diversified, and healthy economies in
    Indian country.
                                     ______

           Prepared Statement of the National Consumer Law Center \1\
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        \1\ Prepared by Olivia Wein, Staff Attorney, National Consumer Law
    Center (202-452-6252, owein@nclcdc.org).
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        The Federal Low Income Home Energy Assistance Program (LIHEAP) \2\
    is the cornerstone of Government efforts to help needy seniors and
    families avoid hypothermia in the winter and heat stress (even death)
    in the summer. LIHEAP is an important safety net program for low-
    income, unemployed, and underemployed families struggling in this
    economy. In fiscal year 2009, the program is expected to assist 7.3
    million low-income households afford their energy bills. Residential
    consumers continue to pay much higher heating bills than in the past,
    and depending on the region of the country and the heating fuel, the
    increase in expenditures for heating fuel have been substantial over
    time. In light of the crucial safety net function of this program in
    protecting the health and well-being of low-income seniors, the
    disabled and families with very young children, we respectfully request
    that LIHEAP be fully funded at its authorized level of $5.1 billion for
    fiscal year 2010 and that advance funding of $5.1 billion be provided
    for the program in fiscal year 2011.
    ---------------------------------------------------------------------------
        \2\ 42 U.S.C. Sec. Sec.  8621 et seq.
    ---------------------------------------------------------------------------
         home energy bills remain high at a time when unemployment and
                           underemployment is growing
        Residential heating expenditures remain at high levels. Average
    residential heating expenditures this winter are expected to be about
    38 percent higher for heating oil, 16 percent higher for natural gas,
    42 percent higher for propane, and 24 percent higher for electricity
    when compared to the 5-year average for 2002-2007.\3\ The steady, high
    energy bills are hitting low-income households struggling in this
    economic downturn. According to the Bureau of Labor Statistics, in
    March 2009, the number of unemployed workers was 13.2 million, with
    half the increase in the number of unemployed occurring within the past
    4 months.\4\ According the Economic Policy Institute, the number of
    involuntary part-time workers nearly doubled to more than 8 million in
    the past year, largely due to full-time workers accepting reduced
    hours.\5\ The hardship low-income households face is also apparent in
    the data below on the number of households falling behind.
    ---------------------------------------------------------------------------
        \3\ Derived from data in the Energy Information Agency, Short-Term
    Energy Outlook (Feb. 2009), Table WF01.
        \4\ US, DOL, Bureau of Labor Statistics, The Employment Situation:
    March 2009 (rel. April 3, 2009).
        \5\ See Ross Eisenbrey and Kathryn Edwards, Downtime: Workers
    forced to settle for fewer hours, Economic Policy Institute (Jan. 14,
    2009).
    ---------------------------------------------------------------------------
    states' data on electric and natural gas disconnections and arrearages
                  show that more households are falling behind
        The steady and dramatic rise in residential energy costs has
    resulted in increases in electric and natural gas arrearages and
    disconnections. For example, in Rhode Island in 2008 there were 8
    percent more service disconnections for nonpayment than in any other
    year on record, and 21 percent of those accounts were not restored.\6\
    A recent national survey by the National Association of Regulatory
    Utility Commissioners found that almost 40 million electricity and
    natural gas residential consumers held nearly $8.7 billion in past-due
    accounts at the end of the 2007-2008 Winter heating season. The survey
    also concluded that in calendar year 2007, 8.7 million residential
    consumers had their electricity or natural gas service terminated for
    failing to pay their bills, with 3.6 million who remained disconnected
    as of this past May 2008.\7\
    ---------------------------------------------------------------------------
        \6\ Analysis of John Howat, senior policy analyst at National
    Consumer Law Center (April 2009).
        \7\ Sandra Sloane, Mitchell Miller, Beverly Barker, Lisa Colosimo,
    ``2008 Individual State Report by NARUC Consumer Affairs Subcommittee
    on Collections Data Gathering.'' (Approved on Nov. 17, 2008 by the
    NARUC Consumers Affairs Committee).
    ---------------------------------------------------------------------------
        Although there are winter utility shut-off moratoria in place in
    many States, not every home is protected against energy shut-offs in
    the middle of winter. As we approach the lifting of winter shut-off
    moratoria, we expect to see a wave of disconnections as households are
    unable to afford the cost of the energy bills. Low-income families are
    falling further behind as we endure year after year of rising home
    energy prices. We expect the number of disconnections to grow and the
    gap between disconnections and reconnections to also grow, especially
    in light of the economic challenges faced by the unemployed and
    underemployed workers.
        Iowa.--Iowa has experienced a steady increase in enrollment for the
    regular LIHEAP program from fiscal year 2007 to fiscal year 2009 with
    86,000 households in 2007; 87,000 in 2008 and projects 95,700 in fiscal
    year 2009.\8\ As a testament to the difference LIHEAP can make for low-
    income households, in February 2009, the number of Iowa low-income
    households with past-due energy accounts and the total amount of the
    low-income arrears were lower than for the past 3 years at this point
    in time (e.g., February 2006, February 2007, and February 2008).
    Comparatively, when looking at the arrearage data for February over
    time for the total residential gas and electric accounts in arrears and
    the amount of those arrears, those numbers are at historic highs.\9\
    ---------------------------------------------------------------------------
        \8\ NEADA press releases from April 25, 2008 and January 12, 2009.
        \9\ Based on data provided by the Iowa Bureau of Energy Assistance.
    ---------------------------------------------------------------------------
        Ohio.--Ohio has experienced a steady and dramatic demand for low-
    income energy assistance. The number of households entering into the
    State's low-income energy affordability program, the Percentage of
    Income Payment Program (PIPP), increased 9 percent from January 2008 to
    January 2009. The increase is an even more dramatic 86 percent between
    January 2003 and January 2009. The total dollar amount owed (arrearage)
    by low-income PIPP customers increased 11 percent from January 2008 to
    January 2009 and 52 percent when comparing PIPP customer arrears from
    January 2003 to January 2009.\10\ Ohio has experienced a steady
    increase in enrollment for the regular LIHEAP program (HEAP) from
    fiscal year 2007 to fiscal year 2009 with 360,000 households in 2007;
    370,000 in 2008 and projects 400,000 in fiscal year 2009.\11\
    ---------------------------------------------------------------------------
        \10\ Public Utilities Commission of Ohio.
        \11\ NEADA press releases from April 25, 2008 and January 12, 2009.
    ---------------------------------------------------------------------------
        Pennsylvania.--Pennsylvania has also experienced a steady increase
    in enrollment for the regular LIHEAP program from fiscal year 2007 to
    fiscal year 2009 with 367,000 households in 2007; 398,000 in 2008 and
    projects 490,000 in fiscal year 2009.\12\ Utilities in Pennsylvania
    that are regulated by the Pennsylvania Public Utility Commission (PA
    PUC) have established universal service programs that assist utility
    customers in paying bills and reducing energy usage. Even with these
    programs, electric and natural gas utility customers find it difficult
    to keep pace with their energy burdens. The PA PUC estimates that more
    than 17,745 households entered the current heating season without heat-
    related utility service--this number includes about 3,373 households
    who are heating with potentially unsafe heating sources such as
    kerosene or electric space heaters and kitchen ovens. In mid-December
    2008, an additional 13,595 residences where electric service was
    previously terminated were vacant and more than 6,442 residences where
    natural gas service was terminated were vacant. In 2008, the number of
    terminations increased 73 percent compared with terminations in 2004.
    As of December 2008, 18.3 percent of residential electric customers and
    16.9 percent of natural gas customers were overdue on their energy
    bills. These 2008 overdue utility bills have increased 9.57 percent
    more than 2007. In addition, in recognition of the increases in media
    reports of deaths of terminated customers the PA PUC implemented a new
    reporting requirement. Utilities in Pennsylvania are now required to
    file reports regarding any incidents involving death at locations where
    residential utility service has been terminated.\13\ The economic
    downturn is putting additional pressures on local human service
    agencies as well. A report on the effect of economy on Pittsburgh,
    Pennsylvania shows a 73.3 percent increase in ``first time'' applicants
    for a range of basic needs assistance, including energy assistance.\14\
    ---------------------------------------------------------------------------
        \12\ NEADA press releases from April 25, 2008 and January 12, 2009.
        \13\ Pennsylvania Public Utility Commission Bureau of Consumer
    Services.
        \14\ Vivien Luk and Stacy Kehoe, Understanding the Impact of the
    Economic Downturn on Pittsburgh Residents and Human Service Agencies,
    the Forbes Funds (November 2008).
    ---------------------------------------------------------------------------
        States are Predicting Record LIHEAP Participation.--NEADA reports
    that for fiscal year 2009, 15 States have projected increases in
    participation of at least 21 percent, with Texas estimating a 201
    percent increase; Florida 200 percent; California 162 percent;
    Tennessee 60 percent; Arkansas 50 percent; Arizona 35 percent; Alaska
    34 percent; New Mexico 26 percent; Oregon 26 percent; Alabama 25
    percent; Massachusetts 25 percent; New Hampshire 25 percent;
    Pennsylvania 23 percent; Connecticut 23 percent; and Delaware 21
    percent.\15\ In Arkansas, many of the community action agencies are
    estimating that about 40 percent of the people contacting them for
    services over the past 8 to 10 months are new applicants;
    overwhelmingly, these new applicants are seeking utility
    assistance.\16\ Thus there is great need for a fully funded LIHEAP
    program in the States.
    ---------------------------------------------------------------------------
        \15\ NEADA press release, Applications for Low Income Energy
    Assistance Reach Record Levels: States Call on Congress to Increase
    Funding for LIHEAP (January 12, 2009).
        \16\ Estimates provided by Arkansas Community Action Agencies
    Association, Inc.
    ---------------------------------------------------------------------------
     liheap is a critical safety net program for the elderly, the disabled
                       and households with young children
        LIHEAP is Vital to Poor Seniors.--Poor seniors are cutting back on
    energy usage because it is not affordable. In general, elder households
    use less total household energy than nonelderly households, which is
    attributable primarily to the smaller dwelling units. However, poor
    elderly households use markedly less energy than nonpoor elderly
    households. Even worse, poor elderly households, on average, consume 12
    percent more energy per square foot of living space (this measurement
    is also referred to as energy intensity) than non-poor elderly
    households. This disparity is attributable to the poorly weatherized
    living spaces and the use of old, inefficient heating equipment and
    appliances.\17\ LIHEAP is critical for helping low-income seniors
    maintain safe temperatures in their homes.
    ---------------------------------------------------------------------------
        \17\ NCLC analysis of U.S. Energy Information Administration, 2001
    Residential Energy Consumption Survey data on elderly energy
    consumption and expenditures.
    ---------------------------------------------------------------------------
        Dire Choices and Dire Consequences.--Recent national studies have
    documented the dire choices low-income households face when energy
    bills are unaffordable. Because adequate heating and cooling are tied
    to the habitability of the home, low-income families will go to great
    lengths to pay their energy bills. Low-income households faced with
    unaffordable energy bills cut back on necessities such as food,
    medicine and medical care.\18\ The U.S. Department of Agriculture has
    released a study that shows the connection between low-income
    households, especially those with elderly persons, experiencing very
    low food security and heating and cooling seasons when energy bills are
    high.\19\ A pediatric study in Boston documented an increase in the
    number of extremely low-weight children, age 6 to 24 months, in the 3
    months following the coldest months, when compared to the rest of the
    year.\20\ Clearly, families are going without food during the winter to
    pay their heating bills, and their children fail to thrive and grow.
    The loss of essential utility services can be devastating, especially
    for poor families that can find themselves facing eviction. A 2007
    Colorado study found that the second leading cause of homelessness for
    families with children is the inability to pay for home energy.\21\
    ---------------------------------------------------------------------------
        \18\ See e.g., National Energy Assistance Directors' Association,
    2008 National Energy Assistance Survey, Tables in section IV, G and H
    (April 2009) (To pay their energy bills 32 percent of LIHEAP recipients
    went without food, 42 percent went without medical or dental care, 38
    percent did not fill or took less than the full dose of a prescribed
    medicine, 15 percent got a payday loan). Available at http://
    www.neada.org/communications/press/2009-04-28.htm.
        \19\ Mark Nord and Linda S. Kantor, Seasonal Variation in Food
    Insecurity Is Associated with Heating and Cooling Costs Among Low-
    Income Elderly Americans, The Journal of Nutrition, 136 (Nov. 2006)
    2939-2944.
        \20\ Deborah A. Frank, MD et al., Heat or Eat: The Low Income Home
    Energy Assistance Program and Nutritional and Health Risks Among
    Children Less Than 3 Years of Age, AAP Pediatrics v. 118, no. 5 (Nov.
    2006) e1293-e1302. See also, Child Health Impact Working Group,
    Unhealthy Consequences: Energy Costs and Child Health: A Child Health
    Impact Assessment Of Energy Costs And The Low Income Home Energy
    Assistance Program (Boston: Nov. 2006) and the Testimony of Dr. Frank
    Before the Senate Committee on Health, Education, Labor and Pensions
    Subcommittee on Children and Families (March 5, 2008).
        \21\ Colorado Interagency Council on Homelessness, Colorado
    Statewide Homeless Count Summer, 2006, research conducted by University
    of Colorado at Denver and Health Sciences Center (Feb. 2007).
    ---------------------------------------------------------------------------
        When people are unable to afford paying their home energy bills,
    dangerous and even fatal results occur. In the winter, families resort
    to using unsafe heating sources, such as space heaters,\22\ ovens and
    burners, all of which are fire hazards. In 2006, 73 percent of home
    heating fire deaths, 43 percent of home heating fire injuries and 51
    percent of property damage from home heating fires involved stationary
    or portable space heaters. In the summer, the inability to keep the
    home cool can be lethal, especially to seniors. According to the CDC,
    older adults, young children and person with chronic medical conditions
    are particularly susceptible to heat-related illness and are at a high
    risk of heat-related death. The CDC reports that 3,442 deaths resulted
    from exposure to extreme heat during 1999-2003.\23\ The CDC also notes
    that air-conditioning is the number one protective factor against heat-
    related illness and death.\24\ LIHEAP assistance helps these vulnerable
    seniors, young children and medically vulnerable persons keep their
    homes at safe temperatures during the winter and summer and also funds
    low-income weatherization work to make homes more energy efficient.
    ---------------------------------------------------------------------------
        \22\ John R. Hall, Jr., Home Fires Involving Heating Equipment:
    Space Heaters (In 2006 there were an estimated 64,100 home fires
    involving space heaters resulting in 540 deaths, 1,400 injuries and
    $943 million in property damage) National Fire Protection Association
    (Jan. 2009).
        \23\ CDC, ``Heat-Related Deaths--United States, 1999-2003'' MMWR
    Weekly, July 28, 2006.
        \24\ CDC, ``Extreme Heat: A Prevention Guide to Promote Your
    Personal Health and Safety'' available at http://emergency.cdc.gov/
    disasters/extremeheat/heat_guide.asp.
    ---------------------------------------------------------------------------
        LIHEAP is an administratively efficient and effective targeted
    health and safety program that works to bring fuel costs within a
    manageable range for vulnerable low-income seniors, the disabled and
    families with young children. LIHEAP must be fully funded at its
    authorized level of $5.1 billion in fiscal year 2010 in light of the
    steady increase in home energy costs and the increased need for
    assistance to protect the health and safety of low-income families by
    making their energy bills more affordable during this economic
    downturn. In addition, fiscal year 2011 advance funding would
    facilitate the efficient administration of the State LIHEAP programs.
    Advanced funding provided certainty of funding levels to states to set
    income guidelines and benefit levels before the start of the heating
    season. States can also plan the components of their program year
    (e.g., amounts set aside for heating, cooling and emergency assistance,
    weatherization, self-sufficiency, and leveraging activities).
                                     ______

         Prepared Statement of the National Coalition of STD Directors
        The National Coalition of STD Directors (NSCD) is a nonprofit,
    nonpartisan association of public health sexually transmitted (STD)
    program directors in the 65 Centers for Disease Control and Prevention
    (CDC) directly funded project areas, which includes all 50 States, 7
    cities, and 8 U.S. territories. As the only national organization with
    a constituency that provides frontline STD services, NCSD is the
    leading national voice for strengthening STD prevention, research and
    treatment. These efforts include advocating for effective policies,
    strategies, and sufficient resources, as well as increasing awareness
    of the medical and social impact of STDs.
        We appreciate this opportunity to provide the subcommittee with
    information about the health crisis caused by the persistent and
    staggeringly high rates of STDs in the United States and about the
    programs of the CDC that combat these diseases.
        The United States has the highest STD rates in the industrialized
    world, with more than 19 million people contracting an STD annually. In
    1 year, our Nation spends more than $8.4 billion to treat the symptoms
    and consequences of STDs. The indirect costs are higher, including lost
    wages and productivity, as well as human costs such as anxiety, shame,
    anger, depression and the challenges of living with infertility or
    cancer. The health consequences of STDs include: chronic pain,
    infertility, pregnancy complications, pelvic inflammatory disease,
    cervical cancer, birth defects, and increased vulnerability to HIV, the
    virus that causes AIDS. Persons with a pre-existing STD have a three-
    to fivefold increased risk of acquiring HIV through sexual contact. In
    addition, studies have shown that HIV-infected persons who are also
    infected with other STDs are more likely to transmit HIV. Comprehensive
    STD treatment can reduce the likelihood of HIV transmission.
        STDs have a disproportionate impact on young people--women, men who
    have sex with men (MSM), and racial and ethnic minorities. Of the
    approximately 19 million new STD infections each year, nearly half are
    among young people ages 15 to 24. Chlamydia, which leads to
    infertility, is the most frequently reported disease in the United
    States. Nearly 1 million women will have a severe case of pelvic
    inflammatory disease due to STDs. The transmission of STDs to babies--
    prenatally, during birth, or after--can cause serious life-long
    complications including physical disabilities, developmental
    disabilities, and death. MSM have historically experienced high rates
    of all STDs, including HIV/AIDS. In 2007, 65 percent of all primary and
    secondary syphilis cases were among MSM. The syphilis rate among males
    is now six times the rate among females, a dramatic disparity that did
    not exist a decade ago, when rates were nearly equivalent between the
    sexes. This trend suggests that the increase in cases among men have
    been primarily among men who have sex with men. Persons of color,
    particularly African-Americans, American Indians/Alaska natives, and
    Hispanics are also at higher risk of contracting STDs. In 2007, the
    rate of chlamydia among African Americans was eight times that of
    whites, for American Indian/Alaska natives it was five times higher
    than whites, and for Hispanics it was three times higher than whites.
    African American women experience syphilis rates 14 times higher than
    white women. Socioeconomic, cultural and linguistic barriers to quality
    healthcare and STD prevention and treatment services have likely
    contributed to a higher prevalence and incidence of STDs among racial
    and ethnic minorities.
        While rates of STDs in this country have continued to skyrocket,
    Federal funding for CDC's Division of STD Prevention has steadily
    declined since fiscal year 2003. For every $1 spent on STD prevention,
    $43 is spent each year on STD-related costs. In addition, for every $1
    spent on research, $92 is spent each year on STD-related costs.
        NSCD requests an fiscal year 2010 funding level of $451.3 million,
    an increase of $299 million, for the STD prevention, treatment, and
    surveillance programs of the CDC. These funds will significantly
    enhance the CDC's ability to reduce STD rates across the country.
    Public Health Infrastructure (+$40 Million)
        Federal funding for CDC's Division of STD Prevention has been
    relatively flat for the past 15 years. The combined effect of this,
    along with steadily increasing rates of STDs and more recently, drastic
    State and local budget cuts due to the economic crisis, STD programs
    are in crisis mode and stretched thinner than ever. STD programs have
    had to cut staff, dramatically cut clinical services or close clinic
    doors altogether, and eliminate critical services such as free condom
    distribution programs. The public health infrastructure must be rebuilt
    and modernized. Investments in training, information and surveillance
    systems, public health laboratories, and better diagnostic technologies
    would increase efficiency, ensure program effectiveness, and protect
    the health of future generations.
    Public Health Workforce (+$24 Million)
        A critical piece of rebuilding the public health infrastructure is
    scaling up the public health workforce. One-quarter of the current
    public health workforce will be eligible to retire by 2012. We must
    invest now in training and retraining the next generation of public
    health professionals. This is particularly critical for STD programs.
    The underpinning of all STD programs is the Disease Intervention
    Specialist (DIS), who provide partner services to individuals infected
    with STDs, their partners, and to other persons who are at increased
    risk for STD infection. DIS are specially trained public health workers
    who are responsible for locating, counseling, and coordinating the
    testing of individuals exposed to an STD. DIS complete an intensive CDC
    training course, which provides a strong foundation in field
    investigation techniques, both on the ground and on the Internet. In
    some States, DIS also assist in the HIV Partner Services program, by
    assisting newly HIV-infected individuals with informing their partners
    of their status and encouraging those partners to seek HIV counseling,
    testing, and related prevention services. DIS also provide surge
    capacity during an emergency response, such as the current swine flu
    epidemic. The versatile expertise of DIS make them indispensable during
    a public health crisis, and also highlights the need for increased
    resources to support the training and hiring of new DIS. The current
    economic crisis has forced many States to freeze the hiring of new DIS
    and even lay off DIS, in spite of increasing STD cases.
    Expand Chlamydia Screening and Infertility Prevention (+$100 Million)
        Chlamydia is the most commonly reported disease in the United
    States, as well as the primary cause of infertility. The Infertility
    Prevention Project (IPP), a collaborative effort between CDC and Office
    of Population Affairs within the Department of Health and Human
    Services, has been working to reduce STD-related infertility for 15
    years. IPP provides funding to screen low-income women for chlamydia
    and gonorrhea in STD and family planning clinics. This project is a
    major success story in STD prevention, having been highly successful in
    reducing new cases of chlamydia and gonorrhea in areas where it has
    been implemented. However, additional resources are needed to bring
    this project to scale and reach a greater number of at-risk women.
    Chlamydia screening has also been shown to be extremely cost effective.
    Among 21 evidence-based clinical services recommended by the U.S.
    Preventive Service Task Force, chlamydia screening for young women
    ranked among the top 5 as having the most health benefits and best
    value for the dollar.
        Additional Federal resources would help support increased chlamydia
    screening in the public sector, expand school-based and correctional-
    based screening, as well as initiate a series of demonstration projects
    in the private sector aimed at increasing private sector screening
    rates.
    Gonorrhea Control and Health Disparities Reduction (+$78 Million)
        Gonorrhea is the second most commonly reported infectious disease
    in the United States. African Americans are the most heavily impacted
    by this disease, with overall rates 19 times greater than that of
    whites in 2007. African-American men aged 15 to 19 years old experience
    gonorrhea rates 39 times higher than white men in the same age group.
    An increasing issue of concern in the treatment of gonorrhea is
    antimicrobial drug resistance. In 2006, 13.8 percent of all gonorrhea
    cases demonstrated resistance, while 39 percent of the cases
    specifically among MSM demonstrated resistance. In 2007, CDC revised
    its gonorrhea treatment guidelines to include only a single class of
    antibiotics.
        Additional Federal resources would be used to monitor antimicrobial
    resistant gonorrhea and test alternate or new drug regimens, initiate
    culturally competent social marketing campaigns, increase screening and
    partner services in hyperendemic areas, and develop demonstration
    research projects to determine the effectiveness and cost-effectiveness
    of gonorrhea prevention and control interventions.
    Syphilis Elimination (+$50 Million)
        The rates of primary and secondary syphilis, the most infectious
    stages of the disease, decreased throughout the 1990s, and in 2000
    reached an all-time low. However, since 2000 as STD funding has
    declined, the syphilis rate in the United States has increased by 76
    percent. Since 1999, the Syphilis Elimination Effort (SEE), a
    collaboration between CDC and State, local, and nongovernmental
    partners, has worked to eliminate syphilis from all areas of the
    country and reduce long-standing health disparities. These strategies
    include: expanded surveillance and outbreak response activities, rapid
    screening and treatment in and out of medical settings, expanded
    laboratory services, strengthened community involvement and agency
    partnerships, and enhanced health promotion. These efforts have been
    shown to be successful, but must be funded adequately. A 2008 study
    suggested that SEE funding in a given year was associated with
    subsequent declines (over the following 2 years) in syphilis rates in a
    given State. The greater a State's per capita syphilis elimination
    funding in a given year, the greater the decline in syphilis rates in
    subsequent years. While the activities of SEE have proven themselves to
    be effective, they must be adequately and consistently funded to
    ultimately eliminate this disease in the United States.
        Additional Federal resources for SEE would be prioritized for
    increased screening, particularly among HIV positive persons and
    pregnant women, the development and evaluation of rapid diagnostic
    tests, implementation of social marketing campaigns targeted towards
    MSM and minority populations, and expanded screening in correctional
    facilities.
    Build a Response to Viral STDs (Herpes, HPV, Hepatitis B)
        More than 45 million Americans, almost 26 percent of the U.S.
    population, are infected with herpes simplex virus (HSV), a treatable
    but incurable viral STD. Improved treatment of HSV is fundamental to
    reducing the rates of transmission. Individuals with herpes are more
    susceptible to acquiring HIV. An estimated 20 million Americans are
    infected with human papillomavirus (HPV), the cause of about 90 percent
    of all cervical cancer cases. CDC would utilize additional funds to
    monitor the HPV vaccine introduction and behavioral impact of HPV
    vaccine through demonstration projects and an expansion of an existing,
    multi-level, multi-year behavioral research project. The most common
    source of hepatitis B virus (HBV) infection among adults is sexual
    contact. Funding is needed to expand prevention efforts on HPV and HBV
    and to deliver education on the availability of preventive vaccines.
                                     ______

            Prepared Statement of the National Down Syndrome Society
        Mr. Chairman and members of the subcommittee: As Chairperson of the
    National Down Syndrome Society, I want to take this opportunity to
    thank you for the leadership role this subcommittee has played over the
    years in supporting and creating awareness on Down syndrome. I am
    pleased to offer the following written testimony regarding
    appropriation requests for Down syndrome in fiscal year 2010.
        There are more than 400,000 people living with Down syndrome in the
    United States, and about 5,000 babies, or 1 in 800, that are born each
    year. Down syndrome occurs in people of all races and economic levels,
    and it is the most frequently occurring chromosomal condition. The
    incidence of births of children with Down syndrome increases with the
    age of the mother. But due to higher fertility rates in younger women,
    80 percent of children with Down syndrome are born to women under 35
    years of age.
        Advancements in the treatment of health problems have allowed
    people with Down syndrome to enjoy fuller and more active lives, and
    become more integrated into the economic and social structures of our
    communities. Unfortunately, while progress has also been made in public
    policies that enhance the lives of individuals with Down syndrome,
    barriers still exist, making it difficult for people to access adequate
    healthcare, housing, employment, and education.
        We have been working with Congress for decades to address these
    challenges and advance public policies that promote the acceptance and
    inclusion of individuals with Down syndrome, and help them to achieve
    their full potential in all aspects of their lives.
        Mr. Chairman, we understand the challenges the subcommittee faces
    in prioritizing requests, we believe that funding the requirements of
    the Prenatally and Postnatally Diagnosed Conditions Awareness Act of
    2007 (Public Law 110-374) is imperative given the significant impact
    Down syndrome has on families and communities across the country and
    the great potential for improvements in quality of life. On behalf of
    the National Down Syndrome Society, we recommend that you appropriate
    $5 million in the fiscal year 2010 to implement the requirements of the
    Prenatally and Postnatally Diagnosed Conditions Awareness Act of 2007.
        As you know, last year, Congress passed the Prenatally and
    Postnatally Diagnosed Conditions Awareness Act of 2007. This new law
    seeks to ensure that pregnant women receiving a positive prenatal
    diagnosis of Down syndrome and parents receiving a postnatal diagnosis
    will receive up-to-date, scientific information about life expectancy,
    clinical course, intellectual and functional development, and prenatal
    and postnatal treatment options. It offers referrals to support
    services such as hotlines, Web sites, informational clearinghouses,
    adoption registries, parent support networks, and Down syndrome and
    other prenatally diagnosed conditions programs. The goal is to create a
    sensitive and coherent process for delivering information about the
    diagnosis across the variety of medical professions and technicians, to
    avoid any conflicting, inaccurate, or incomplete information. Also, the
    legislation would promote the rapid establishments of links to
    community supports and services for parents who choose to take their
    baby with Down syndrome home or for those who choose to have their
    child adopted.
        It is estimated that more than 1,000 prenatal tests are available
    or in development. Included among them are tests for conditions that
    are not life-threatening, could be helped by surgery or medical care,
    or don't appear until adulthood. The prognoses for people with some
    prenatally diagnosable disabilities have been improving markedly in
    recent years, leaving medical professionals scrambling to keep up with
    changing data. By including $5 million in the fiscal year 2010 Labor,
    Health and Human Services, and Education, and Related Agencies
    appropriations bill, the Department of Health and Human Services (HHS)
    will be able to fund its responsibilities to:
      --Collect and distribute information relating to Down syndrome and
            other prenatally or postnatally diagnosed conditions;
      --Coordinate the provision of supportive services for patients
            receiving a positive diagnosis of a prenatally or postnatally
            diagnosed condition; and
      --Oversee the new requirements for healthcare providers established
            by the law. The funding is also needed to carry out the
            requirement that the CDC assist State and local health
            departments to integrate testing results into surveillance
            systems.
        Mr. Chairman, thank you for your time and attention. Given the
    considerable impact this condition has on families and communities
    across the country, the promise of further assistance and improving
    research outcomes for individuals with Down syndrome is crucial. We are
    thrilled beyond measure that Congress enacted this legislation and hope
    that funding this request will help to shift the way the Nation regards
    individuals with disabilities. Through providing accurate, updated
    information about diagnosable conditions like Down syndrome to pregnant
    women, the expectation is that individuals and families will make
    better, more-informed decisions. But the bigger impact will be better
    understanding on the part of the American people about the nature of
    disability and the value of these citizens to their families, their
    communities and to our country. Should you have any questions or
    require additional information, please feel free to call on me.
                                     ______

                 Prepared Statement of the NephCure Foundation
                               one family's story
        Chairman Cochran and members of the subcommittee thank you for the
    opportunity to provide written testimony today, I am Dee Ryan and my
    husband is Lieutenant Colonel John Kevin Ryan, an Iraq war veteran. I
    would like to tell you about my 6-year-old daughter Jenna's nephrotic
    syndrome (NS), a medical problem caused by rare diseases of the kidney
    filter. When affected, these filters leak protein from the blood into
    the urine and often cause kidney failure requiring dialysis or kidney
    transplantation. We have been told by our physician that Jenna has 1 of
    2 filter diseases called Minimal Change Disease or Focal and Segmental
    Glomerulosclerosis (FSGS). According to a Harvard University report
    there are presently 73,000 people in the United States who have lost
    their kidneys as a result of FSGS. Unfortunately, the causes of FSGS
    and other filter diseases are very poorly understood.
        In October 2007 my daughter began to experience general swelling of
    her body and intermittent abdominal pain, fatigue, and general malaise.
    Jenna began to develop a cough and her stomach became dramatically
    distended. We rushed Jenna to the emergency room where her breathing
    became more and more labored and her pulse raced. She had symptoms of
    pulmonary edema, tachycardia, hypertension, and pneumonia. Her lab
    results showed a large amount of protein in the urine and a low
    concentration of the blood protein albumin, consistent with the
    diagnosis of FSGS. Jenna's condition did not begin to stabilize for
    several frightening days.
        Following her release from the hospital we had to place Jenna on a
    strict diet which limited her consumption of sodium to no more than
    1,000 mg per day. Additionally, Jenna was placed on a steroid regimen
    for the next 3 months. We were instructed to monitor her urine protein
    levels and to watch for swelling and signs of infection, in order to
    avoid common complications such as overwhelming infection or blood
    clots. Because of her disease and its treatment, which requires strong
    suppression of the immune system, Jenna did have a serious bacterial
    infection several months after she began treatment.
        We are frightened by her doctor's warnings that NS and its
    treatment are associated with growth retardation and other medical
    complications including heart disease. As a result of NS, Jenna has
    developed hypercholesterolemia and we worry about the effects the
    steroids may have on her bones and development. This is a lot for a
    little girl in kindergarten to endure.
        Jenna's prognosis is currently unknown because NS can reoccur. Even
    more concerning to us is that Jenna may eventually lose her kidneys
    entirely and need dialysis or a kidney transplant. While kidney
    transplantation might sound like a cure, in the case of FSGS, the
    disease commonly reappears after transplantation. And even with a
    transplant, end stage renal disease caused by FSGS dramatically
    shortens one's life span.
        The NephCure Foundation (NCF) has been very helpful to my family.
    They have provided us with educational information about NS, Minimal
    Change Disease, and FSGS and the organization works to provide grant
    funding to scientists for research into the cause and cure of NS.
        Mr. Chairman, because the causes of NS are poorly understood, and
    because we have a great deal to learn in order to be able to
    effectively treat NS, I am asking you to please significantly increase
    funding for the National Institutes of Health. Also, please support the
    establishment of a collaborative research network that would allow
    scientists to create a patient registry and biobank for NS/FSGS, and
    that would allow coordinated studies of these deadly diseases for the
    first time. Finally, please urge the National Institute of Diabetes and
    Digestive and Kidney Disease (NIDDK) to continue to focus on FSGS/NS
    research in general, consistent with the recent program announcement
    entitled Grants for Basic Research in Glomerular Disease (R01) (PA-07-
    367).
        Mr. Chairman, on behalf of the thousands of people suffering from
    NS and FSGS and NCF, thank you for this opportunity to submit this
    testimony to the subcommittee and for your consideration of my request;
    Thank you.
                            more research is needed
        We are no closer to finding the cause or the cure of FSGS.
    Scientists tell us that much more research needs to be done on the
    basic science behind the disease.
        NCF, the University of Michigan, and other important university
    research health centers have come together to support the establishment
    of the Nephrotic Syndrome Rare Disease Clinical Research Network. This
    network is a new collaboration between research institutions and NCF
    supporting research on NS and FSGS. This initiative has tremendous
    potential to make significant advancements in NS and FSGS research by
    pooling efforts and resources. The addition of Federal resources to
    this important initiative is crucial to ensuring the best possible
    outcomes for the Nephrotic Syndrome Rare Disease Clinical Research
    Network occur.
        NCF is also grateful to the NIDDK for issuing of a program
    announcement (PA) that serves to initiate grant proposals on glomerular
    disease The PA, issued in March of 2006, is glomerular-disease
    specific. The announcement will utilize the R01 mechanism to award
    researchers funding.
        We ask the subcommittee to encourage the ORD to support the
    Nephrotic Syndrome Rare Disease Clinical Research Network to expand
    FSGS research. We also ask the NIDDK to continue to issue glomerular
    disease program announcements.
                  too little education about a growing problem
        When glomerular disease strikes, the resulting NS causes a loss of
    protein in the urine and edema. The edema often manifests itself as
    puffy eyelids, a symptom that many parents and physicians mistake as
    allergies. With experts projecting a substantial increase in nephrotic
    syndrome in the coming years, there is a clear need to educate
    pediatricians and family physicians about glomerular disease and its
    symptoms.
        We also applaud the work of the NIDDK in establishing the National
    Kidney Disease Education Program (NKDEP), and we seek your support in
    urging the NIDDK to make sure that glomerular disease remains a focus
    of the NKDEP.
        We ask the subcommittee to encourage the NIDDK to have glomerular
    disease receive high visibility in its education and outreach efforts,
    and to continue these efforts in conjunction with NCF's work. These
    efforts should be targeted towards both physicians and patients.
                glomerular disease strikes minority populations
        Nephrologists tell us that glomerular disease strikes a
    disproportionate number of African Americans. No one knows why this is,
    but some studies have suggested that a genetic sensitivity to sodium
    may be partly responsible. DNA studies of African Americans who suffer
    from FSGS may lead to insights that would benefit the thousands of
    African Americans who suffer from kidney disease.
        I ask that the NIH pay special attention to why this disease
    affects African Americans to such a large degree. NCF wishes to work
    with the NIDDK and the National Center for Minority Health and Health
    Disparities (NCMHD) to encourage the creation of programs to study the
    high incidence of glomerular disease within the African-American
    population.
        There is also evidence to suggest that the incidence of glomerular
    disease is higher among Hispanic Americans than in the general
    population. An article in the February 2006 edition of the NIDDK
    publication Recent Advances and Emerging Opportunities, discussed the
    case of Frankie Cervantes, a 6-year-old boy of Mexican and Panamanian
    descent. Frankie has FSGS received a transplanted kidney from his
    mother. We applaud the NIDDK for highlighting FSGS in their
    publication, and for translating the article about Frankie into both
    English and Spanish. Only through similar efforts at cross-cultural
    education can the African-American and Hispanic-American communities
    learn more about glomerular disease.
        We ask the subcommittee to join with us in urging the NIDDK and
    NCMHD to collaborate on research that studies the incidence and cause
    of this disease among minority populations. We also ask that the NIDDK
    and the NCMHD undertake culturally appropriate efforts aimed at
    educating minority populations about glomerular disease.
                          patient registry and biobank
        Experts currently believe glomerular disease is increasing in
    frequency and it is often misdiagnosed or undetected and, as a result,
    is often unreported. Since many cases of glomerular disease are
    unreported, it is difficult to ascertain different aspects of the
    disease and to form more comprehensive data sets on the patient
    population. While databases and registries have helped defeat other
    diseases, one does not exist for FSGS.
        The development of a biobank would be beneficial in understanding
    the genetic components of glomerular disease and their corresponding
    interactions with environmental factors.
        We ask the subcommittee to support the funding of the first-ever
    national database/registry for FSGS within NIDDK. Experts say that the
    incidence of FSGS is increasing and that the disease is often
    misdiagnosed, undetected, or unrecorded. We also ask the subcommittee
    support the development of a biobank as a further means of
    understanding the causes of FSGS, both genetic and environmental.
                                     ______

    Prepared Statement of the National Federation of Community Broadcasters
        Thank you for the opportunity to submit testimony to this
    subcommittee regarding the appropriation for the Corporation for Public
    Broadcasting (CPB). As the President and CEO of the National Federation
    of Community Broadcasters (NFCB), I speak on behalf of 250 community
    radio stations and related individuals and organizations across the
    country. Nearly half our members are rural stations and half are
    controlled by people of color. In addition, our members include many
    Low Power FM stations that are putting new local voices on the
    airwaves. NFCB is the sole national organization representing this
    group of stations which provide independent, local service in the
    smallest communities of this country as well as the largest
    metropolitan areas.
        In summary, the points we wish to make to this subcommittee are
    that NFCB:
      --Requests $542 million in funding for CPB for fiscal year 2012;
      --Supports a $307 million supplemental appropriation in fiscal year
            2010 to ensure that public broadcasting is not lost to any
            parts of the country because of the economic crisis;
      --Requests $40 million in fiscal year 2010 for conversion of public
            radio and television to digital broadcasting;
      --Requests $27 million in fiscal year 2010 for replacement of the
            radio interconnection system;
      --Requests that advance funding for CPB is maintained to preserve
            journalistic integrity and facilitate planning and local
            fundraising by public broadcasters;
      --Supports CPB activities in facilitating programming and services to
            Native American, African-American, and Latino radio stations;
      --Supports CPB's efforts to help public radio stations utilize new
            distribution technologies and requests that the subcommittee
            ensure that these technologies are available to all public
            radio services and not just the ones with the greatest
            resources.
        Community Radio fully supports the appropriation of $542 million in
    Federal funding for the Corporation for Public Broadcasting in fiscal
    year 2012. Federal support distributed through CPB is an essential
    resource for rural stations and for those serving communities of color.
    These stations provide critical, life-saving information to their
    listeners and are often in communities with very small populations and
    limited economic bases, thus the community is unable to financially
    support the station without Federal funds. For example, these stations
    offer programming in languages other than English or Spanish, they can
    offer emergency information targeted for a particular geographic area,
    and can offer in-depth programming on public health issues.
        In larger towns and cities, sustaining grants from CPB enable
    community radio stations to provide a reliable source of noncommercial
    programming about the communities themselves. Local programming is an
    increasingly rare commodity in a Nation that is dominated by national
    program services and concentrated ownership of the media. Federal
    funding allows an alternative to exist in these larger markets. And
    with large newspaper shedding journalists, local community radio may be
    one of the only outlets able to pick up the slack in coverage of local
    political matters.
        For more than 30 years, CPB appropriations have been enacted 2
    years in advance. This insulation has allowed pubic broadcasting to
    grow into a respected, independent, national resource that leverages
    its Federal support with significant local funds. Knowing what funding
    will be available in advance has allowed local stations to plan for
    programming and community service and to explore additional
    nongovernmental support to augment the Federal funds. Most important,
    the insulation that advance funding provides ``go[es] a long way toward
    eliminating both the risk of and the appearance of undue interference
    with and control of public broadcasting.'' (House Report 94-245.)
        For the past few years, CPB has increased support to rural stations
    and committed resources to help public radio take advantage of new
    technologies such as the Internet, satellite radio, and digital
    broadcasting. We support these new technologies we can better serve the
    American people, but want to ensure that smaller stations with more
    limited resources are not left behind in this technological transition.
    We ask that the subcommittee include language in the appropriation that
    will ensure that funds are available to help the entire public radio
    system, particularly rural and minority stations, utilize new
    technology.
        NFCB commends CPB for the leadership it has shown in supporting and
    fostering programming services to Latino stations and Native American
    stations. For example, Satelite Radio Bilingue provides 24 hours of
    programming to stations across the United States and Puerto Rico
    addressing issues of particular interest to the Latino population in
    Spanish and English. At the same time, Native Voice One (NV1) is
    distributing politically and culturally relevant programming to Native
    American stations. There are now more than 33 stations in the United
    States controlled by and serving Native Americans.
        Five years ago, CPB funded the establishment of the Center for
    Native American Public Radio (CNAPR). After 4 years in operation, CNAPR
    has assisted with the renewal of licenses and expansion of the
    interconnection system to all Native stations and has advanced the
    opportunity for native nations to own their own, locally controlled
    station. In the process of this work, it was recognized that radio
    would not be available to all native nations and broadband and other
    new technologies would be necessary. CNAPR has been repositioned as
    Native Public Media (NPM) and is working hard to double the number of
    native stations within the next 3 years. These stations are critical in
    serving local, isolated communities (all but one are on Indian
    Reservations) and in preserving cultures that are in danger of being
    lost. CPB's 2003 assessment recognized that ``. . . Native Radio faces
    enormous challenges and operates in very difficult environments.'' CPB
    funding is critical to these rural, minority stations. The funding of
    the Intertribal Native Radio Summit by CPB in 2001 helped to gather
    these isolated stations together into a system of stations that can
    support one another. The CPB assessment goes on to say ``Nevertheless,
    the Native Radio system is relatively new, fragile and still needs help
    building its capacity at this time in its development.'' NPM promises
    to leverage additional new funding to ensure that these stations
    continue providing essential services to their communities.
        CPB also funded a Summit for Latino Public Radio which took place
    in September 2002 in Rohnert Park, California, home of the first Latino
    public radio station. This year, CPB has provided funding to the Latino
    Public Radio Consortium to develop a strategic plan and business model
    to expand the service of public radio to the Latino population. The
    Latino population is growing in this country and requires news services
    geared toward them in order to fully participate in civic life.
    Hispanics were 12.5 percent of the population in 2000, by 2007 they
    were 15 percent, and the number is only growing.\1\
    ---------------------------------------------------------------------------
        \1\ Pew Hispanic Center, Statistical Portrait of Hispanics in the
    United States, 2007.
    ---------------------------------------------------------------------------
        CPB plays an extremely important role in the public and Community
    radio system: They convene discussions on critical issues facing us as
    a system. They support research so that we have a better understanding
    of how we are serving listeners. And, they provide funding for
    programming, new ventures, expansion to new audiences, and projects
    that improve the efficiency of the system. This is particularly
    important at a time when there are so many changes in the radio and
    media environment with media consolidation and new distribution
    technologies.
        Community radio supports a $307 million supplemental appropriation
    in fiscal year 2010 to ensure that public broadcasting is not lost to
    any parts of the country because of the economic crisis. Public
    Broadcasting is requesting a one-time investment of Federal resources
    to help stations maintain local service and assist their communities
    cope with the economic crisis and to assure continuity of public
    broadcasting service to the American people. Financial contributions
    from corporations, foundations, institutions are down dramatically and
    listeners contributions, the main source of funding for Community radio
    are beginning to be impacted by the growing unemployment. Community
    stations are critical sources of local information and it is essential
    that they be able to continue to provide their unique local service.
        Community radio supports $40 million in fiscal year 2010 for the
    conversion to digital broadcasting by public radio and television.
    While public television's digital conversion needs are mandated by the
    FCC, public radio is converting to digital to provide more public
    service and to keep up with commercial radio. The Federal
    Communications Commission has approved a standard for digital radio
    transmission that will allow multicasting. CPB has provided funding for
    more than 650 radio transmitters to convert to digital. Of those, 160
    are multicasting two or more streams of programming. The development of
    second and third audio channels will potentially double or triple the
    service that public radio can provide listeners, particularly in un-
    served and underserved communities. However, this initial funding still
    leaves nearly 200 radio transmitters that must ultimately convert to
    digital or become obsolete.
        Community radio strongly supports $27 million in fiscal year 2009
    for the public radio interconnection system. Public radio pioneered the
    use of satellite technology to distribute programming. The Public Radio
    Satellite System's recently launched ContentDepot continues this
    tradition of cutting edge technology. Satellite capacity supporting it
    must be renewed and upgrades are necessary at the station and network
    operations levels. Interconnection is vital to the delivery of the
    high-quality programming that public broadcasting provides to the
    American people. This is the last year of a 3-year request for $80
    million to the complete the project.
        We are in a period of tremendous change. ``Radio is well on its way
    to becoming something altogether new--a medium called audio.'' \2\ The
    digital movement is transforming the way we do things; new distribution
    avenues like digital satellite broadcasting and the Internet are
    changing how we define our business; and, the concentration of
    ownership in commercial radio makes public radio in general, and
    Community radio in particular, more important as a local voice than we
    have ever been. New Low Power FM stations are providing local voices in
    their communities an avenue of expression, and many new community
    stations will be going on the air within the next few years. Community
    radio is providing essential local emergency information, programming
    about the local impact of major global events taking place, and
    culturally relevant information and entertainment in native languages,
    as well as helping to preserve cultures that are in danger of dying
    out. During the natural disasters of recent years, radio proved once
    again that it is the most dependable and available medium for getting
    emergency information to the public.
    ---------------------------------------------------------------------------
        \2\ The State of the News Media, Pew Project for Excellence in
    Journalism, 2008.
    ---------------------------------------------------------------------------
        During these challenging times, the role of CPB as a convener of
    the system becomes even more important. The funding that it provides
    will allow smaller stations to participate alongside larger stations
    that have more resources as we move into a new era of communications.
                                     ______

            Prepared Statement of the National Fragile X Foundation
        Mr. Chairman and members of the subcommittee: As President of the
    Board of Directors for the National Fragile X Foundation, I want to
    take this opportunity to thank you for the leadership role this
    subcommittee has played over the years in the fight for Fragile X-
    associated Disorders. I am pleased to offer the following written
    testimony regarding appropriation requests in fiscal year 2010.
        Fragile X-associated Disorders are genetic disorders that cause
    behavioral, developmental, and language disabilities across a person's
    lifespan. It is linked to a mutation on the X chromosome, and is the
    most commonly inherited form of intellectual disabilities. Fragile X is
    also linked to reproductive problems in women including early menopause
    Fragile X-associated primary ovarian insufficiency (FXPOI) and, a
    Parkinson's-like condition in older male carriers Fragile X-associated
    tremor/ataxia syndrome (FXTAS). More than 100,000 Americans have
    Fragile X Syndrome and more than 1 million Americans carry a Fragile X
    mutation and either have, or are at risk for developing a Fragile X-
    associated disorder.
        These appropriations requests are significant in order to continue
    to build the infrastructure needed and assure continued progress toward
    targeted treatments for Fragile X-associated Disorders. The National
    Fragile X Foundation has invested significantly in the creation of the
    Fragile X Clinical & Research Consortium, a network of 20 clinics
    across the country who collaborate to align data collection efforts,
    participate in clinical trials of new pharmacological agents, share
    research findings and develop consistent best practices and standards
    of care for the treatment of Fragile X-associated Disorders.
        In addition, these appropriations requests would assist in building
    upon important work already initiated by the Federal Government. We
    have been successful at building programs at the Centers for Disease
    Control and Prevention (CDC), National Institutes of Health (NIH), and
    Health Resources and Services Administration (HRSA). The CDC has
    recognized the value of this important collaboration, and has provided
    resources to ensure the continued growth and evolution of the Fragile X
    Clinical & Research Consortium. Previously, the CDC had secured nearly
    $4.5 million in funding since fiscal year 2005 for the CDC Fragile X
    National Public Health Initiative. The program is currently funded at
    just more than $1.8 million annually. Furthermore, the CDC has worked
    with Congress to define the highest impact public health priorities for
    the Fragile X community. These efforts led to:
      --Development of a newborn screening test for fragile X syndrome;
      --Single gene resource network for fragile X syndrome;
      --Fragile X syndrome cascade testing and genetic counseling
            protocols;
      --Fragile X Family Needs Assessment; and
      --Support for the Fragile X Clinical & Research Consortium.
        Moreover, public efforts, including three National Institute of
    Child Health and Human Development (NICHD)-funded Fragile X Research
    Centers, has proven critically important in the development of
    effective treatments. The development of key therapeutics for Fragile X
    will likely be effective for a much larger population living with
    related autism spectrum disorders. We recognize that in order to
    translate basic science findings into viable treatments for Fragile X,
    additional coordination and resources are required at the NIH.
        The Fragile X community has been working to promote the work of NIH
    to ensure improved coordination among the various Institutes to ensure
    the most effective use of Federal research dollars devoted to Fragile
    X-associated Disorders (i.e., Fragile X Syndrome, Fragile X-associated
    Tremor/Ataxia Syndrome, and Fragile X-associated Primary Ovarian
    Insufficiency). Congress has advocated for greater resources at NIH
    leading to an increase in NIH Fragile X-associated Disorders efforts
    from approximately $12 million annually in 2001 to approximately $27
    million in fiscal year 2009. With this increase, NIH recently awarded
    the largest Fragile X Federal research grant in history, a 5-year,
    $21.8 million grant to a team of researchers at the UC Davis School of
    Medicine and M.I.N.D. Institute.
        As you know, the fiscal year 2008 Departments of Labor, Health and
    Human Services, and Education, and Related Agencies Appropriations Act
    included language directing the NIH, under the leadership of the NICHD
    (Senate Report 110-107) to coordinate, intensify, and expedite research
    efforts related to Fragile X-associated Disorders. The law specifically
    directed the NIH to convene a scientific session in 2008 to develop
    pathways to new opportunities for collaborative, directed research
    across Institutes, and to produce a blueprint of coordinated research
    strategies and public-private partnership opportunities for Fragile X.
    The NICHD was directed to lead this initiative and was urged to
    collaborate with the three existing federally funded Centers of
    Excellence as well as the Fragile X Clinical & Research Consortium.
        In response to this directive, NICHD leadership convened a 2-day
    scientific session and created a rigorous working group infrastructure
    consisting of the world's leading researchers and NIH staff to ensure
    timely development of the NIH Research Blueprint on Fragile-X
    associated disorders. The leadership team at NICHD and three working
    groups prepared a comprehensive blueprint that will provide a clear
    direction for future research activities for Fragile-X associated
    disorders. The final draft of this report was completed in late 2008,
    and will be published by NIH this week.
        Mr. Chairman, we respectfully request Congress to continue its
    support of these ongoing initiatives, and to support increased
    prioritization of Fragile X-associated Disorders at the CDC and NIH in
    order to accelerate the critical work being accomplished through the
    Fragile X Clinical & Research Consortium.
        The National Fragile X Foundation recommends that you appropriate
    the following fiscal year 2010 requests:
      --A $2 million increase in funding from fiscal year 2009 levels, for
            the National Fragile X Public Health Initiative and other CDC
            initiatives to:
        --Focus efforts on identifying ongoing needs, effective treatments,
                and positive outcomes for families by increasing
                epidemiological research, surveillance, screening efforts,
                and the introduction of early interventions and supports
                for individuals living with Fragile X-associated Disorders.
        --Focus on the continued growth and development of initiatives that
                support health promotion activities and foster rapid, high-
                impact translational research practice for the successful
                treatment Fragile X-associated Disorders, including ongoing
                collaborative activities with the Fragile X Clinical &
                Research Consortium.
      --Report language and increased resources for Fragile X at the NIH
            to:
        --Support continued implementation of the recommendations outlined
                in the NIH Fragile X-associated Disorders Research
                Blueprint as well as increased NIH support for the Fragile
                X Clinical & Research Consortium.
        --Enhance its efforts across its Institutes to translate basic
                science findings into viable treatments for Fragile X, and
                encourage clinical drug trials for this orphan indication.
        --Maximize Fragile X resources by ensuring that appropriate
                resources and direction is provided to implement the
                objectives outlined in the Fragile X Research Blueprint.
        --Strengthen and broaden research on Fragile X- associated
                disorders (i.e., FXTAS and FXPOI).
        Furthermore, as part of our overall to increase support and
    prioritization of Fragile X-associated Disorders at the Federal level,
    the Fragile X community is also working with the Defense Subcommittee
    on Appropriations to include Fragile X-associated Disorders among the
    list of eligible healthcare conditions for targeted biomedical research
    funding through the U.S. Department of Defense. The success from all of
    these intense public and private research efforts, including the NIH
    and CDC, has brought discoveries to bear for Fragile X-associated
    Disorders. However, we feel continued expansion of Federal efforts and
    resources at each of these agencies will be instrumental to conduct
    promising research on Fragile X-associated Disorders.
        Mr. Chairman, thank you for your time and attention. We, at the
    National Fragile X Foundation, believe that continued awareness and
    support for enhancing Fragile X research and translational activities
    is imperative. Given the significant impact this condition has on
    families and communities across the country, the promise of a
    breakthrough for the treatment and cure of this disease is urgent.
    Should you have any questions or require additional information, please
    feel free to call on me.
                                     ______

    Prepared Statement of the National Health Care for the Homeless Council
        The National Health Care for the Homeless Council respectfully asks
    the Senate Committee on Appropriations to strengthen and expand the
    Nation's health centers by appropriating $2.9 billion for the
    Consolidated Health Centers Program in fiscal year 2010.
        The National Health Care for the Homeless Council is a membership
    organization engaged in education and advocacy to improve healthcare
    for homeless persons and all Americans. We represent 111 organizational
    members, including 100 Health Care for the Homeless (HCH) projects, and
    more than 700 individuals who provide care to people experiencing
    homelessness throughout the country.
        Homelessness and Health.--Poverty, lack of affordable housing, and
    the lack of comprehensive health insurance are among the underlying
    structural causes of homelessness. For those struggling to pay for
    housing and other basic needs, the onset of a serious illness or
    disability easily can result in homelessness following the depletion of
    financial resources. The experience of homelessness causes poor health,
    and poor health is exacerbated by restricted access to appropriate
    healthcare--which only prolongs homelessness. Additional barriers to
    healthcare access include lack of transportation, inflexible clinic
    hours, complex requirements to qualify for public health insurance, and
    mandatory unaffordable co-payments for various services.
        Mainstream healthcare safety net providers often fail to meet the
    needs of homeless people. In the absence of universal healthcare, the
    Federal Government supports a separate healthcare system for low-income
    and uninsured people. Community Health Centers and publicly funded
    mental health and addictions programs form the core of this healthcare
    safety net. Unfortunately, limited resources, lack of experience with
    this population, and insufficient linkages to a full range of health
    and supportive services seriously restrict the ability of mainstream
    providers to meet the unique needs of people experiencing homelessness.
        The Federal Health Care for the Homeless Program--administered by
    the Health Resources and Services Administration (HRSA)--currently
    supports 205 HCH projects in all 50 States, the District of Columbia,
    and Puerto Rico. Congress established HCH in 1987 to provide targeted
    services for people experiencing homelessness, including primary and
    behavioral healthcare along with social services, as well as intensive
    outreach and case management to link clients with appropriate
    resources. Approximately 70 percent of those served by HCH projects
    lack comprehensive health insurance. The HCH program has been
    reauthorized three times, most recently in 2008 with passage of the
    Health Care Safety Net Act. HCH projects served 742,588 in 2007--a
    sizable number, but far below the 3.5 million Americans who annually
    experience homelessness. Authorizing language designates 8.7 percent of
    the total Health Center appropriation to support the HCH program.
        Community Health Centers.--Over the past several years, the
    expansion of community health centers has received bipartisan support
    from Members of Congress. Federally-Qualified Health Centers (FQHCs)
    consistently have proven their effectiveness in delivering
    comprehensive medical care to underserved populations. Though health
    centers currently serve more than 16 million people annually, at least
    56 million Americans--both insured and uninsured--face inadequate
    access to primary care due to a shortage of physicians and other
    providers. Without sufficient access to care, the health problems of
    the insured and underinsured are exacerbated, resulting in costly
    treatment, medical complications, and even premature death.
        Within the current economic context, a massive unmet need remains
    for health center resources despite years of incremental expansion
    through the Health Center Growth Initiative. The deteriorating economy
    leaves more Americans unemployed, at risk of homelessness, and in need
    of health services. According to the Department of Labor, unemployment
    jumped to 8.5 percent in March 2009, the highest in 14 years. With
    continued increases in unemployment, more Americans are expected to
    lose health coverage, thus placing additional burden upon community
    health centers.
        Fiscal Year 2010 Appropriations.--In recognition of the growing
    need for primary healthcare services, the Senate Committee on
    Appropriations along with other Members of Congress has been supportive
    of strengthening and expanding community health centers. In the current
    year, Congress appropriated $2.2 billion--$125 million above the fiscal
    year 2008 appropriation. This included $56 million in base grant
    adjustments and provided a total of $191 million (8.7 percent) for the
    HCH program.
        To continue strengthening the Nation's health center
    infrastructure, we encourage the Senate Committee on Appropriations
    Subcommittee on Labor, Health and Human Services, and Education, and
    Related Agencies to appropriate $2.9 billion for the Community Health
    Center program (including $252 million for the HCH program) in fiscal
    year 2010. The National Council's request is consistent with planned
    increases outlined in the Access for All America Act (S. 486). This
    important legislation, introduced by Senator Bernie Sanders, would
    quadruple the amount of funding for community health centers over the
    next 5 years.
        The National Council applauds Congress for its strong support of
    community health centers. We thank Chairman Harkin and the Senate
    Committee on Appropriations Subcommittee on Labor, Health and Human
    Service, and Education, and Related Agencies for your consideration of
    this testimony.
                                     ______

              Prepared Statement of the National Marfan Foundation
        Mr. Chairman, thank you for the opportunity to submit testimony
    regarding the fiscal year 2010 budget for the National Heart, Lung and
    Blood Institute (NHLBI), the National Institute of Arthritis,
    Musculoskeletal and Skin Diseases (NIAMS), and the Centers for Disease
    Control and Prevention (CDC). The National Marfan Foundation is
    grateful to you and the subcommittee for your strong support of the
    National Institutes of Health and CDC, particularly as it relates to
    life-threatening genetic disorders such as Marfan syndrome. Thanks in
    part to your leadership we are at a time of unprecedented hope for our
    patients.
        It is estimated that 200,000 people in the United States are
    affected by Marfan syndrome or a related condition. Marfan syndrome is
    a genetic disorder of the connective tissue that can affect many areas
    of the body, including the heart, eyes, skeleton, lungs, and blood
    vessels. It is progressive condition and can cause deterioration in
    each of these body systems. The most serious and life-threatening
    aspect of the syndrome is a weakening of the aorta. The aorta is the
    largest artery carrying oxygenated blood from the heart. Over time,
    many Marfan syndrome patients experience a dramatic weakening of the
    aorta which can cause the vessel to dissect and tear.
        Early surgical intervention can prevent a dissection and strengthen
    the aorta and the aortic valves. If preventive surgery is performed
    before a dissection occurs, the success rate of the procedure is more
    than 95 percent. If surgery is initiated after a dissection has
    occurred, the success rate drops below 50 percent. Aortic dissection is
    a leading killer in the United States, and 20 percent of the people it
    affects have a genetic predisposition, like Marfan syndrome, to
    developing the complication.
        Fortunately, new research offers hope that a commonly prescribed
    blood pressure medication might be effective in preventing this
    frequent and devastating event.
                                     nhlbi
    Pediatric Heart Network Clinical Trial
        NMF applauds NHLBI for its leadership in advancing a landmark
    clinical trail on Marfan syndrome. Under the direction of Dr. Lynn
    Mahoney and Dr. Gail Pearson, the Institute's Pediatric Heart Network
    has spearheaded a multicenter study focused on the potential benefits
    of a commonly prescribed blood pressure medication (losartan) on aortic
    growth in Marfan syndrome patients.
        NHLBI Director Dr. Elizabeth Nabel describes this promising
    research well:

        ``After the discovery that Marfan syndrome is associated with the
    mutation in the gene encoding a protein called fibrillin-1, researchers
    tried for many years, without success, to develop treatment strategies
    that involved repair of replacement of fibrillin-1. Then a major
    breakthrough occurred with the discovery that one of the functions of
    fibrillin-1 is to bind to another protein, TGF-beta, and regulate its
    effects. After careful analysis revealed aberrant TGF-beta activity in
    patients with Marfan syndrome, researchers began to concentrate on
    treating Marfan syndrome by normalizing the activity of TGF-beta.
    Losartan, which is known to affect TGF-beta activity, was tested in a
    mouse model of Marfan syndrome and the results showed that drug was
    remarkably effective in blocking the development of aortic aneurysms,
    as well as lung defects associated with the syndrome.
        Based on this promising finding, the NHLBI Pediatric Heart Network,
    has undertaken a clinical trial of losartan in patients with Marfan
    syndrome. About 600 patients aged 6 months to 25 years will be enrolled
    and followed for 3 years. This development illustrates the outstanding
    value of basic science discoveries, and identifying new directions for
    clinical applications. Moreover, the ability to organize and initiate a
    clinical trial within months of such a discovery is testimony to
    effectiveness of the NHLBI Network in providing the infrastructure and
    expertise to capitalize on new findings as they emerge.''

        Dr. Hal Dietz, the Victor A. McKusick Professor of Genetics in the
    McKusick-Nathans Institute of Genetic Medicine at the Johns Hopkins
    University School of Medicine, and the director of the William S.
    Smilow Center for Marfan Syndrome Research, is the driving force behind
    this groundbreaking research. Dr. Dietz uncovered the role that
    fibrillin-1 and TGF-beta play in aortic enlargement, and demonstrated
    the benefits of losartan in halting aortic growth in mice. He is the
    reason we have reached this time of such promise and NMF is proud to
    have supported Dr. Dietz's cutting-edge research for many years.
        NMF is also proud to actively support the losartan clinical trial
    in partnership with the Pediatric Heart Network. Throughout the life of
    the trial we will provide support for patient travel costs, coverage of
    select echocardiogram examinations, and funding for ancillary studies.
    These ancillary studies will explore the impact that losartan has on
    other manifestations of Marfan syndrome.
    NHLBI ``Working Group on Research in Marfan Syndrome and Related
            Conditions''
        In April 2007, NHLBI convened a ``Working Group on Research in
    Marfan Syndrome and Related Conditions.'' Chaired by Dr. Dietz, this
    panel was comprised of experts in all aspects of basic and clinical
    science related to the disorder. The panel was charged with identifying
    key recommendations for advancing the field of research in the coming
    decade. The recommendations of the Working Group are as follows:

        ``Scientific opportunities to advance this field are conferred by
    technological advances in gene discovery, the ability to dissect
    cellular processes at the molecular level and imaging, and the
    establishment of multi-disciplinary teams. The barriers to progress are
    addressed through the following recommendations, which are also
    consistent with Goals and Challenges in the NHLBI Strategic Plan.
      --Existing registries should be expanded or new registries developed
            to define the presentation, natural history, and clinical
            history of aneurysm syndromes.
      --Biological and aortic tissue sample collection should be
            incorporated into every clinical research program on Marfan
            syndrome and related disorders and funds should be provided to
            ensure that this occurs. Such resources, once established,
            should be widely shared among investigators.
      --An Aortic Aneurysm Clinical Trials Network (ACTnet) should be
            developed to test both surgical and medical therapies in
            patients with thoracic aortic aneurysms. Partnership in this
            effort should be sought with industry, academic organizations,
            foundations, and other governmental entities.
      --The identification of novel therapeutic targets and biomarkers
            should be facilitated by the development of genetically defined
            animal models and the expanded use of genomic, proteomic, and
            functional analyses. There is a specific need to understand
            cellular pathways that are altered leading to aneurysms and
            dissections, and to develop robust in vivo reporter assays to
            monitor TGFb and other cellular signaling cascades.
      --The developmental underpinnings of apparently acquired phenotypes
            should be explored. This effort will be facilitated by the
            dedicated analysis of both prenatal and early postnatal tissues
            in genetically defined animal models and through the expanded
            availability to researchers of surgical specimens from affected
            children and young adults.''

        We look forward to working closely with NHLBI to pursue these
    important research goals and ask the subcommittee to support the
    recommendations of the Working Group. Mr. Chairman, for fiscal year
    2010 NMF joins with other professional and patient organizations in
    recommending a 7 percent for NHLBI.
                                     niams
        NMF is proud of its longstanding partnership with NIAMS. Dr. Steven
    Katz has been a strong proponent of basic research on Marfan syndrome
    during his tenure as NIAMS Director and has generously supported
    several ``Conferences on Heritable Disorders of Connective Tissue.''
    Moreover, the Institute has provided invaluable support for Dr. Dietz's
    mouse model studies. The discoveries of fibrillin-1, TGF-beta, and
    their role in muscle regeneration and connective tissue function were
    made possible in part through collaboration with NIAMS.
        As the losartan clinical trail moves forward, we hope to expand our
    partnership with NIAMS to support related studies that fall under the
    mission and jurisdiction of the Institute. One of the areas of great
    interest to researchers and patients is the role that losartan may play
    in strengthening muscle tissue in Marfan patients. We would welcome an
    opportunity to partner with NIAMS in support of this research moving
    forward.
        For fiscal year 2010, NMF recommends a 7 percent increase for
    NIAMS.
                                      cdc
        Mr. Chairman, we are grateful for the subcommittee's encouragement
    in recent years of collaboration between CDC and the Marfan syndrome
    community. One of the most important things we can do to prevent
    untimely deaths from aortic aneurysms is to increase awareness of
    Marfan syndrome and related connective tissue disorders.
        Despite our ongoing efforts to raise awareness among the general
    public and healthcare providers, we know of too many families who have
    lost a loved one because of a missed diagnosis.
        We are very appreciative of CDC's support of our 25th annual
    patient conference taking place in Rochester, Minnesota August 6-9,
    2009. We have also discussed other potential collaborations with the
    National Center on Birth Defects and Development Disabilities focused
    on education and early diagnosis. We ask the subcommittee to continue
    to encourage CDC to work with us to initiate these activities in fiscal
    year 2010.
        For fiscal year 2010, NMF joins with the CDC Coalition in
    recommending an appropriation of $8.6 billion for core CDC programs.
                                     ______

      Prepared Statement of the National Network to End Domestic Violence
        Chairman Harkin, Ranking Member Cochran, and members of the
    subcommittee, thank you for the opportunity to submit written testimony
    to the Labor, Health and Human Services, and Education, an Related
    Agencies (LHHS) Appropriations Subcommittee. We are grateful to the
    subcommittee for your continued leadership and your investment in
    lifesaving programs that prevent and end domestic violence.
        The National Network to End Domestic Violence (NNEDV) is a
    membership and advocacy organization representing the 56 State and U.S.
    territory domestic violence coalitions. NNEDV provides a national voice
    for the coalitions, their more than 2,000 local domestic violence
    member programs, and the millions of domestic violence survivors who
    turn to them for services. In their work with victims and their
    families, our members see the impact that abuse and violence have on
    the lives of children who are vulnerable both as witnesses to violence
    and as victims themselves.
        Over the last 25 years, millions of victims have found refuge and
    safety through domestic violence programs funded by the Family Violence
    Prevention and Services Act (FVPSA). The success of this LHHS-funded
    program, however, is threatened by budget stagnation and an increasing
    demand for services. Small budget increases, while appreciated, simply
    cannot meet the desperate needs of victims. Now, more than ever, we
    need to increase our country's investment in this vital, cost-effective
    program. Increases to FVPSA funding will help bridge the unconscionable
    gap created by an increased demand and inadequate funding. On behalf of
    the millions of victims and families that our member programs serve
    each year, we urge you to fully fund the FVPSA/Battered Women's Shelter
    Services program (FVPSA) at $175 million, the National Domestic
    Violence Hotline at $3.5 million, and the Community Initiatives to
    Prevent Abuse (DELTA) program at $6 million in the fiscal year 2010
    congressional budget.
                               domestic violence
        Domestic violence is pervasive and life-threatening. According to
    the 2005 Bureau of Justice Statistics' Family Violence Statistics, of
    the total victims of violence between 1998 and 2002, 11 percent were
    victims of family violence.\1\ One in four women has been beaten or
    raped by a husband, boyfriend, or partner in her lifetime.\2\ In 2005
    alone, 1,181 women were murdered by an intimate partner in the United
    States \3\ and approximately one-third of all female murder victims are
    killed by an intimate partner.\4\
    ---------------------------------------------------------------------------
        \1\ U.S. Department of Justice, Bureau of Justice Statistics,
    Family Violence Statistics: Including Statistics on Strangers and
    Acquaintances, June 2005.
        \2\ Tjaden, Patricia & Thoennes, Nancy. National Institute of
    Justice and the Centers of Disease Control and Prevention, ``Extent,
    Nature and Consequences of Intimate Partner Violence: Findings from the
    National Violence Against Women Survey,'' 2000. The Centers for Disease
    Control (CDC) (2008). Adverse Health Conditions and Health Risk
    Behaviors Associated with Intimate Partner Violence, United States,
    2005.
        \3\ Bureau of Justice Statistics, Homicide Trends in the U.S. from
    1976-2005. US Department of Justice. (2008).
        \4\ Bureau of Justice Statistics, Homicide Trends from 1976-1999.
    U.S. Department of Justice. (2001)
    ---------------------------------------------------------------------------
        The cycle of intergenerational violence is perpetuated as children
    witness violence. It is estimated that a staggering 15.5 million
    children are exposed to domestic violence every year.\5\ Children who
    are exposed to domestic violence are more likely to exhibit behavioral
    and physical health problems including depression, anxiety, and
    violence towards peers.\6\ They are also more likely to attempt
    suicide, abuse drugs and alcohol, run away from home, engage in teenage
    prostitution, and perpetrate sexual assault.\7\ One study found that
    men exposed to physical abuse, sexual abuse, and adult domestic
    violence as children were almost four times more likely than other men
    to have perpetrated domestic violence as adults.\8\
    ---------------------------------------------------------------------------
        \5\ McDonald, R., et al. (2006). ``Estimating the Number of
    American Children Living in Partner-Violence Families.'' Journal of
    Family Psychology, 30(1), 137-142.
        \6\ Jaffe, P. and Sudermann, M., ``Child Witness of Women Abuse:
    Research and Community Responses,'' in Stith, S. and Straus, M.,
    Understanding Partner Violence: Prevalence, Causes, Consequences, and
    Solutions. Families in Focus Services, Vol. II. Minneapolis, MN:
    National Council on Family Relations, 1995.
        \7\ Wolfe, D.A., Wekerle, C., Reitzel, D. and Gough, R.,
    ``Strategies to Address Violence in the Lives of High Risk Youth.'' In
    Peled, E., Jaffe, P.G. and Edleson, J.L. (eds.), Ending the Cycle of
    Violence: Community Responses to Children of Battered Women. New York:
    Sage Publications. 1995.
        \8\ Greendfeld, L. A. (1997). Sex Offences and Offenders: An
    Analysis of Date on Rape and Sexual Assault. Washington, DC. Bureau of
    Justice Statistics, U.S. Department of Justice.
    ---------------------------------------------------------------------------
        Domestic violence is not just a crime; it is a public health crisis
    that leads to chronic health conditions, disabilities, lost work time,
    frequent trips to the emergency room and, all too often, serious injury
    or death.
        In addition to the terrible cost domestic and sexual violence have
    on the lives of individual victims and their families, these crimes
    cost taxpayers and communities. In fact, the cost of intimate partner
    violence exceeds $5.8 billion each year, $4.1 billion of which is for
    direct medical and mental healthcare services.\9\ Research shows that
    for every 100,000 women between 18 and 64 enrolled, intimate partner
    violence costs a health insurance plan $19.3 million each year.\10\
    Domestic violence costs U.S. employers an estimated $3 to $13 billion
    annually.\11\
    ---------------------------------------------------------------------------
        \9\ National Center for Injury Prevention and Control. Costs of
    Intimate Partner Violence Against Women in the United States. Atlanta
    (GA): Centers for Disease Control and Prevention; 2003.
        \10\ Ibid.
        \11\ Bureau of National Affairs Special Rep. No. 32, Violence and
    Stress: The Work/Family Connection 2 (1990); Joan Zorza, Women
    Battering: High Costs and the State of the Law, Clearinghouse Rev.,
    Vol. 28, No. 4,383,385; Supra note 10.
    ---------------------------------------------------------------------------
            the family violence prevention and services act (fvpsa)
        Despite this grim reality, we know that when immediate, essential
    services are available victims can escape from life-threatening
    violence and begin to rebuild their shattered lives.
        FVPSA has significantly enhanced community-based domestic violence
    intervention and prevention efforts since it was first authorized by
    Congress in 1984. Administered by the Department of Health and Human
    Services Administration on Children and Families through a State
    formula grant, FVPSA provides funding to States, territories and tribes
    to support domestic violence services in their communities using a
    population-based formula. These essential services that are at the core
    of ending domestic violence: emergency shelters, hotlines, counseling
    and advocacy, primary and secondary prevention--immediate crisis
    response and the comprehensive support to help victims put their lives
    back together. FVPSA also authorizes the Community Initiatives to
    Prevent Abuse program (frequently referred to as Domestic Violence
    Prevention Enhancement and Leadership Through Alliances (DELTA) Grants)
    and the National Domestic Violence Hotline. Working together, these
    FVPSA programs have made significant progress toward ending domestic
    violence and keeping families and communities safe. Since its passage
    in 1984, FVPSA remains the only Federal funding directly for shelter
    programs.
        There are approximately 2,000 FVPSA-funded community-based domestic
    violence programs for victims and their children, providing emergency
    shelter to approximately 300,000 victims and offering services such as
    counseling, crisis lines, safety planning, legal assistance, and
    preventative education to millions of adults and children annually.\12\
    In just 1 day in 2008, 60,799 victims were served by 1,553 domestic
    violence programs. Of the 20,307 victims in emergency shelter that day,
    nearly 50 percent were children.\13\ Programs answered 21,683 hotline
    calls and trained 30,210 community members.
    ---------------------------------------------------------------------------
        \12\ National Coalition Against Domestic Violence, Detailed Shelter
    Surveys (2001).
        \13\ Domestic Violence Counts 08: A 24-hour census of domestic
    violence shelters and services across the United States. The National
    Network to End Domestic Violence. (Jan. 2009).
    ---------------------------------------------------------------------------
        These effective programs save and help rebuild lives. A recently
    released multi-State study shows conclusively that the Nation's
    domestic violence shelters are addressing both urgent and long-term
    needs of victims of violence, and are helping victims protect
    themselves and their children.\14\ Research shows that shelter programs
    are among the most effective resources for victims with abusive
    partners \15\ and that staying at a shelter or working with a domestic
    violence advocate significantly reduced the likelihood that a victim
    would be abused again and improved the victim's quality of life.\16\
    The impact of being and feeling safe cannot be underestimated--when
    asked what he liked best about staying in the shelter, a 10-year-old
    boy in Maryland replied, ``I can sleep at night.''
    ---------------------------------------------------------------------------
        \14\ Lyon, E., Lane S. (2009). Meeting Survivors' Needs: A Multi-
    State Study of Domestic Violence Shelter Experiences. National Resource
    Center on Domestic Violence and UConn School of Social Work. Found at
    http://www.vawnet.org.
        \15\ See: Bennett, L., Riger, S., Schewe, P., Howard, A., & Wasco,
    S. (2004). Effectiveness of hotline, advocacy, counseling and shelter
    services for victims of domestic violence: A statewide evaluation.
    Journal of Interpersonal Violence, 19(7), 815-829; Bowker, L. H., &
    Maurer, L. (1985). The importance of sheltering in the lives of
    battered women. Response to the Victimization of Women and Children, 8,
    2-8; Gordon, J. S. (1996). ``Community services for abused women: A
    review of perceived usefulness and efficacy.'' Journal of Family
    Violence 11(4): 315-329; Sedlak, A. J. (1988). Prevention of wife
    abuse. In V. B. Van Hasselt, R. L. Morrison, A. S. Bellack, & M. Hersen
    (Eds.), Handbook of Family Violence (pp. 319-358). NY: Plenum Press;
    Straus, M. A., Gelles, R. J., & Steinmetz, S. K. (1980). Behind closed
    doors: Violence in the American family. NY: Anchor Press; Tutty, L. M.,
    Weaver, G., & Rothery, M. (1999). Residents' views of the efficacy of
    shelter services for assaulted women. Violence Against Women, 5(8),
    898-925.
        \16\ See: Berk, R. A., Newton, P. J., & Berk, S. F. (1986). What a
    difference a day makes: An empirical study of the impact of shelters
    for battered women. Journal of Marriage and the Family, 48, 481-490;
    Bybee, D.I., & Sullivan, C.M. (2002). The process through which a
    strengths-based intervention resulted in positive change for battered
    women over time. American Journal of Community Psychology, 30(1), 103-
    132; Constantino, R., Kim, Y., & Crane, P.A. (2005). Effects of a
    social support intervention on health outcomes in residents of a
    domestic violence shelter: A pilot study. Issues in Mental Health
    Nursing, 26, 575-590; Goodkind, J., Sullivan, C.M., & Bybee, D.I.
    (2004). A contextual analysis of battered women's safety planning.
    Violence Against Women, 10(5), 514-533; Sullivan, C.M. (2000). A model
    for effectively advocating for women with abusive partners. In J.P.
    Vincent & E.N. Jouriles (Eds.), Domestic violence: Guidelines for
    research-informed practice (pp. 126-143). London: Jessica Kingsley
    Publishers; Sullivan, C.M., & Bybee, D.I. (1999). Reducing violence
    using community-based advocacy for women with abusive partners. Journal
    of Consulting and Clinical Psychology, 67(1), 43-53.
    ---------------------------------------------------------------------------
        Once FVPSA appropriations reach $130 million, a portion will be set
    aside solely for children's services. Battered women's shelters and
    domestic violence programs provide safety and support for children, but
    struggle to meet the demand for children's services. They see the needs
    of children who are recovering from the trauma of witnessing or
    experiencing abuse and they are eager to implement new and expanded
    children's programming.
        The Community Initiatives to Prevent Abuse/DELTA Grants program
    supports community-based primary prevention that address the underlying
    causes of domestic violence in order to stop abuse before it starts.
    DELTA is administered by the Centers for Disease Control and
    Prevention, National Center for Injury Prevention and Control, and it
    is one of the few funding sources for primary prevention work. DELTA
    programs use innovative strategies including peer education programs
    for men about family and relationships, community change initiatives
    focused on engaging men in prevention efforts, school-based education
    to prevent youth bullying that often carries into adulthood, and youth-
    led initiatives to prevent dating violence and promote healthy
    relationships.
        FVPSA also includes the National Domestic Violence Hotline, a 24-
    hour, confidential, toll-free hotline, located in Texas. Since opening
    in 1996, the National Domestic Violence Hotline has received more than
    2 million calls from individuals in need of support and assistance.
    Highly trained hotline advocates provide support, information,
    referrals, safety planning, and crisis intervention to hundreds of
    thousands of domestic violence victims and perpetrators. More than 60
    percent of callers report that their call to the hotline is the first
    time they open up about the abusive relationship.
                                the funding gap
        Due to the overwhelming success of Violence Against Women Act
    (VAWA) and FVPSA funded programs, more and more victims are coming
    forward for help each year. This rising demand for services, without a
    concurrent increase in funding, means that many desperate victims are
    turned away from life-saving services. In just 1 day last year, nearly
    9,000 requests for services went unmet across the country due to a lack
    of resources, including 3,286 requests for emergency shelter.\17\
    Additionally, the National Domestic Violence Hotline was unable to
    answer 42,500 calls (17 percent of the total) because they lacked the
    resources to answer the calls.
    ---------------------------------------------------------------------------
        \17\ Domestic Violence Counts 08: A 24-Hour census of domestic
    violence shelters and services across the United States. The National
    Network to End Domestic Violence. (Jan. 2009).
    ---------------------------------------------------------------------------
        The economic crisis further exacerbates the gap created by the
    increasing demand for services and the lack of adequate resources.
    While economic hard times do not cause violence, the economic stresses
    can increase the frequency and level of violence in a home. With fewer
    personal, family, and community resources upon which to rely, more
    victims turn to domestic violence programs for help. A survey of
    domestic violence shelters across the country revealed that 3 out of 4
    domestic violence shelters have seen an increase in women seeking
    assistance from abuse since September 2008, a major turning point in
    the U.S. economy. Just as more victims are seeking services, programs
    are facing cutbacks from State and country funding sources, as well as
    philanthropic dollars. Many programs have been forced to lay off staff
    and cuts services--a number of programs have even been forced to close
    their doors permanently.
        Laurie Schipper, Executive Director of the Iowa Coalition Against
    Domestic Violence explains the stark consequences of this reality, ``If
    women have nowhere to go, especially in rural areas, women and kids are
    going to die. It's difficult to overstate the gravity of this.'' \18\
    ---------------------------------------------------------------------------
        \18\ Alex, Tom. Wife flees, alleging decades of abuse.
    DesMoinesRegister.com, April 18, 2009. Available at: http://
    www.desmoinesregister.com/apps/pbcs.dll/article?AID=/20090418/NEWS01/
    904180322.
    ---------------------------------------------------------------------------
                             fvpsa reauthorization
        Due to a busy congressional calendar, FVPSA expired in 2008 and has
    yet to be reauthorized. The Senate HELP Committee is currently working
    to reauthorize FVPSA, along with the Child Abuse Prevention and
    Treatment Act. Advocates remain concerned, however, that while FVPSA
    remains expired programs will be further jeopardized. We call on the
    Senate LHHS Appropriations Subcommittee to include report language in
    the final appropriations bill that acknowledges the vital work of FVPSA
    and directs the funding to be spent in a way consistent with its
    authorization.
        NNEDV chairs a national coalition of FVPSA stakeholders who have
    delineated clear priorities for the FVPSA reauthorization.
    Collectively, we want to see FVPSA continue its success while expanding
    to reach the needs of victims who have historically been underserved.
    These needed improvements will require commitment and investment from
    the Appropriations Committee.
                       investing in services saves lives
        In the fiscal year 2008 congressional budget, FVPSA funding was cut
    by $2.1 million, bringing FVPSA funding to $122.6, which is $52.5
    million below the authorized level of $175 million. We applaud the
    subcommittee's commitment to these programs, evidenced in the modest
    funding increases allocated in fiscal year 2009. FVPSA was funded at
    $127.7 million (a $5 million increase from fiscal year 2008), the
    National Domestic Violence Hotline was funded at $3.2 million (a $0.2
    million increase from fiscal year 2008), and DELTA was funded at $5.5
    million (a $0.5 million increase from fiscal year 2008). While these
    increases will pay dividends over time by preventing other costly
    social ills, in order to meet the ever-growing demand for services, it
    is essential that Congress continue to provide steady increases.
        The President's fiscal year 2010 budget proposal requests level
    funding for all three programs. Yet we know that level funding simply
    will not bridge the gap in funding. Congress should invest in FVPSA not
    only to meet the needs of victims in life-threatening situations but
    also to prevent future social ills.
        Fully funding FVPSA at $175 million, the hotline at $3.5 million
    and DELTA at $5.5 million will allow communities across the country to
    continue to provide critically needed direct services to victims of
    domestic violence and their children, which will help to prevent
    homicides and break the cycle of violence.
        Without effective intervention, domestic violence will repeat
    itself and continue to impact successive generations. FVPSA is a
    critical component in breaking the cycle of violence affecting our
    children, families and communities. FVPSA funding, has begun to make
    our country a safer place for families, victims and communities. Now,
    however, this phenomenal progress is in jeopardy. We have seen a
    reduction in homicides and the incidence of these heinous crimes. Yet
    these tough economic times, combined with funding cuts forcing shelters
    to close, real victims face life-threatening situations with no
    support. Every day shelters and service providers must turn away
    families in danger due to lack of resources. While a tough economy may
    tempt lawmakers to cut or maintain existing funding levels, we cannot
    allow this unmet need to continue.
        By prioritizing these vital, cost-effective funding streams,
    Congress will help to break the cycle of domestic violence in our
    country.
                                     ______

            Prepared Statement of the National Psoriasis Foundation
        The National Psoriasis Foundation (NPF) appreciates the opportunity
    to submit written testimony for the record regarding Federal funding
    for psoriasis and psoriatic arthritis research for fiscal year 2010.
    NPF serves as the Nation's largest patient-driven, nonprofit, voluntary
    association committed to finding a cure for psoriasis and psoriatic
    arthritis, which affects as many as 7.5 million Americans, and
    eliminating their devastating effects. Psoriasis is among the most
    prevalent autoimmune diseases.
        As part of our mission, we educate health professionals, the public
    and policymakers to increase public awareness and understanding of the
    challenges faced by people with psoriasis and psoriatic arthritis.
    Moreover, NPF maintains a strong commitment to securing public policies
    and programs that support its focus of education, advocacy, and
    research toward better treatments and a cure. NPF specifically seeks to
    advance public and private efforts to improve treatment of these
    diseases, identify a cure and ensure that all people with psoriasis and
    psoriatic arthritis have access to the medical care and treatment
    options they need to live the highest quality of life possible.
        NPF stands ready to partner with policymakers at the local, State,
    and Federal levels to advance policies and programs that will reduce
    and prevent suffering from psoriasis and psoriatic arthritis.
    Specifically, NPF advocates that in fiscal year 2010 the National
    Institutes of Health (NIH) receive an additional $2.1 billion for a
    total allocation of $32.5 billion to support new investigator-initiated
    research grants for genetic, clinical, and basic research related to
    the understanding of the cellular and molecular mechanisms of psoriasis
    and psoriatic arthritis, as well as studies to explore the nascent
    understanding of co-morbidities, such as obesity, depression and heart
    disease that may be associated with inflammation in the skin and
    joints. In addition, we urge that Congress provide $1.5 million in
    fiscal year 2010 to the Centers for Disease Control and Prevention
    (CDC) to support such data collection to increase understanding of the
    comorbidities associated with psoriasis, examine the relationship of
    psoriasis to other public health concerns, such as the high rate of
    smoking and obesity among those with the disease, and gain insight into
    the long-term impact and treatment of these two conditions.
                the impact of psoriasis and psoriatic arthritis
        According to the NIH, as many as 7.5 million Americans have
    psoriasis--an immune-mediated, genetic, chronic, inflammatory, painful,
    disfiguring, and life-altering disease that requires life-long
    sophisticated medical intervention and care, and imposes serious
    adverse effects on the individuals and families affected. On average,
    17,000 people with psoriasis live in each Congressional District.
        Psoriasis typically first strikes between the ages of 15 and 25,
    but can occur at any time. It lasts a lifetime. Unfortunately,
    psoriasis often is overlooked or dismissed, because it typically does
    not cause death. It is commonly and incorrectly considered by insurers,
    employers, policymakers, and the public as a mere annoyance--a
    superficial problem, mistakenly thought to be contagious and/or due to
    poor hygiene. Yet, together psoriasis and psoriatic arthritis impose
    significant economic costs on individuals and society. Total direct and
    indirect healthcare costs of psoriasis are calculated at more than
    $11,250,000,000 annually with work loss accounting for 40 percent of
    the cost burden.
        There is mounting evidence that people with psoriasis are at
    elevated risk for myriad other serious, chronic, and life-threatening
    conditions. Although data are still emerging on the relationship of
    psoriasis to other diseases and their ensuing costs to the medical
    system, it is clear that psoriasis goes hand-in-hand with co-
    morbidities, such as Crohn's disease, diabetes, metabolic syndrome,
    obesity, hypertension, heart attack, cardiovascular disease, liver
    disease, and psoriatic arthritis--which occurs in up to 30 percent of
    people with psoriasis. Other recent studies have found that people with
    severe psoriasis have a 50 percent higher mortality risk and that these
    patients die 3 to 6 years younger than those who do not have psoriasis.
    Of serious concern is that studies have shown that psoriasis causes as
    much disability as other major chronic diseases, and individuals with
    psoriasis are twice as likely to have thoughts of suicide, as people
    without psoriasis or with other chronic conditions.
        Despite some recent breakthroughs, many people with psoriasis and
    psoriatic arthritis remain in need of improved quality of life and
    effective, safe, and affordable therapies, which could be delivered
    through an increased Federal commitment to genetic, clinical, and basic
    research. Research holds the key to improved treatment of these
    diseases, better diagnosis of psoriatic arthritis and eventually a cure
    for both conditions.
               federal psoriasis and psoriatic arthritis research
        Although overall NIH funding levels improved for psoriasis research
    in fiscal year 2007, 3 out of 5 NIH agencies decreased psoriasis
    funding that same year. NPF is concerned that at the historical and
    current rate of psoriasis funding, NIH funding is not keeping pace with
    research needs, nor is the investment commensurate with the impact of
    the disease. Within the NIH, the National Institute of Arthritis and
    Musculoskeletal and Skin Diseases (NIAMS), the National Center for
    Research Resources, the National Human Genome Research Institute, and
    the National Institute of Allergy and Infectious Diseases are the
    principal Federal Government agencies that currently support psoriasis
    research. Additionally, research activities that relate to psoriasis or
    psoriatic arthritis also have been undertaken at the National Cancer
    Institute. An analysis of longitudinal Federal funding data shows that,
    on average over the past decade, NIAMS has spent less than $1 per
    person with psoriasis per year.
        Adequate investment in psoriasis and psoriatic arthritis in fiscal
    year 2010 and beyond is imperative, because a rare opportunity for
    breakthroughs in both conditions is presenting itself at this time. A
    convergence of findings reached through various types of studies has
    stimulated new ideas about the mechanisms involved in psoriasis.
        It has taken nearly 30 years to understand that psoriasis is not
    solely a disease of the skin, but also of the immune system. Finally,
    scientists are identifying the genes immune cells involved in
    psoriasis--findings that will help improve understanding of which cells
    or molecular processes should be targeted in psoriasis drug
    development. With these important advances, we are poised and
    positioned, as never before, to identify and develop a permanent method
    of control for psoriasis and, eventually, a cure. Greater funding of
    genetics, immunology and clinical research focused on understanding the
    mechanisms of psoriasis and psoriatic arthritis is needed. Key areas
    for additional support and exploration include:
      --Studying the genetic susceptibility of psoriasis;
      --Developing animal models of psoriasis;
      --Identifying the environmental and lifestyle triggers for psoriasis;
      --Studying a number of important epidemiologic issues, such as the
            risk of heart attack, diabetes, increased mortality, and
            lymphoma in psoriasis patients;
      --Identifying and examining immune cells and inflammatory processes
            involved in psoriasis;
      -- Examining the relationship between psoriasis and mental illnesses,
            such as depression and suicidal ideation; and
      --Elucidating psoriatic arthritis specific genes and other
            biomarkers.
         the role of cdc in psoriasis and psoriatic arthritis research
        NPF is concerned that there have been very few efforts to collect
    epidemiological and other related data on individuals with psoriasis
    and psoriatic arthritis. Researchers and clinicians continue to be
    limited in their longitudinal understanding of these conditions and
    their effects on individual patients. There are many mysteries related
    to psoriasis and psoriatic arthritis. For example, we know of people
    who never had any evidence of disease who, after falling ill with the
    flu or spiking a fear, wake the next day to be covered in psoriasis
    plaques. Why? A treatment could work well for an individual for years
    and then suddenly become ineffective. Why?
        Researchers agree that collecting data through a patient registry
    would help increase the understanding of: the other chronic conditions
    that co-occur with psoriasis; how factors like age or gender impact the
    course and burden of psoriasis; and how certain environmental exposures
    might contribute to the occurrence and severity of psoriasis and
    psoriatic arthritis. In turn, this information would help improve
    treatments and advance efforts toward a cure. CDC psoriasis and
    psoriatic arthritis data collection efforts would help answer myriad
    questions about these autoimmune conditions, contribute to improved
    disease treatment and management, and further the Nation's efforts to
    find a cure.
        For 3 years, your subcommittee has encouraged CDC to undertake data
    collection, and we very much appreciate your recognition of this much-
    needed effort. We have met with CDC staff to offer our assistance and
    expertise, however, it is clear the agency must receive specific,
    dedicated funding so it has the resources necessary to develop a
    registry. To that end, NPF respectfully requests that the subcommittee
    allocate $1.5 million in fiscal year 2010 for the National Center for
    Chronic Disease Prevention and Health Promotion (NCCDPHP) within the
    CDC to examine and develop options and recommendations for the creation
    of a National Psoriasis and Psoriatic Arthritis Patient Registry. A
    national patient registry that collects longitudinal patient data will
    help researchers to learn about key attributes, such as response to
    treatment, substantiating the waxing and waning of psoriasis,
    understanding associated manifestations like nail disease and
    arthritis, and the relationship of psoriasis to other public health
    concerns.
                            funding request summary
        NPF recognizes that Congress and the Nation face unprecedented
    fiscal challenges. However, we also believe that greater fiscal year
    2010 investment in biomedical and epidemiologic research at NIH and CDC
    will prove simulative to the economy and bear fruit with regard to the
    development of new, safe, effective, and long-lasting treatments and--
    ultimately--a cure for psoriasis and psoriatic arthritis. We thank the
    subcommittee in advance for providing the following allocations:
      --$32.4 billion to NIH and its Institutes and Centers that play an
            integral role in psoriasis and psoriatic arthritis research and
            urge them to initiate and/or expand psoriasis and psoriatic
            arthritis research and;
      --$1.5 million to the NCCDPHP within the CDC to collect data on
            psoriasis and psoriatic arthritis and begin to establish a
            patient registry to improve the knowledge base of the
            longitudinal impact of these diseases on the individuals they
            affect.
                                   conclusion
        On behalf of NPF's Board of Trustees and the as many as 7.5 million
    individual with psoriasis and psoriatic arthritis who we represent,
    thank you for this opportunity to submit written testimony regarding
    the fiscal year 2010 funding levels necessary to ensure that our Nation
    adequately addresses psoriasis and psoriatic arthritis and to make
    gains in improving therapies and eventually attaining a cure. We
    believe that additional research undertaken at the NIH coupled with
    epidemiologic efforts at the CDC together will help advance the
    Nation's efforts to improve treatments and identify a cure for
    psoriasis and psoriatic arthritis. Please feel free to contact us at
    any time; we are happy to be a resource to subcommittee members and
    your staff. We very much appreciate the subcommittee's attention to--
    and consideration of--our requests.
                                     ______

                  Prepared Statement of National Public Radio
        Thank you Chairman Inouye and Senator Cochran for the opportunity
    to offer testimony on behalf of National Public Radio (NPR), our more
    than 850 public radio station partners, and for other producers and
    distributors of public radio programming including American Public
    Media, Public Radio International, the Public Radio Exchange, and many,
    many stations, both large and small, that create and distribute content
    through the Public Radio Satellite System (PRSS).
        The state of public radio today is both sobering and heartening.
    While the economic crisis has undermined the financial stability of the
    public radio system, the audience is tuning at record levels. But
    without your help, we will not be able to continue to achieve our
    public service mission, and your expectations.
                      an additional investment in stations
        Public broadcasting is requesting $307 million--$96 million for
    public radio stations and $211 million for public television stations--
    in additional emergency investment funding for the fiscal year 2010
    budget of the Corporation for Public Broadcasting (CPB). This action is
    necessary to offset the tide of losses at public broadcasting stations.
    This one-time investment of Federal resources will help protect
    thousands of station jobs now at risk, and assure continuity in
    services used daily by tens of millions of Americans. These funds are
    in addition to the $420 million that Congress approved 2 years ago as
    part of the advance funding process.
        The funds we are requesting only partially close the expected 2-
    year revenue shortfall of almost $170 million at the public radio
    station level, plus an additional $55 million in loses at NPR. The
    remainder will come about as a result of significant cost cutting at
    the local and national levels. Every week brings another announcement
    of a service reduction or employment layoff at public broadcasting
    stations. In fact, a survey last month of locally licensed and operated
    public radio stations projected more than a 46 percent reduction in
    financial support from local and State government agencies, a 23
    percent decline in foundation and philanthropic contributions and a 23
    percent drop in underwriting from local businesses.
        Public broadcasting's contribution to America's democracy is more
    important today than at anytime during our four decades of public
    service. More than 33 million people each week are tuning into public
    radio programming and listening to member stations. Our audience has
    grown 66 percent in the past 10 years, bucking a precipitous decline in
    other media and stands in sharp contrast with the general overall
    decline in radio listening. Consider that public radio programming
    today reaches more people than the circulation of USA Today, the Wall
    Street Journal, the New York Times, Los Angeles Times, the Washington
    Post and the next top 45 newspapers combined.
        Stations in every State have become living embodiments of
    journalistic excellence, providing news, information and cultural
    programming that have become increasingly rare in other media. Public
    radio programming is rooted in the fundamentals of accuracy,
    transparency, independence, balance, and fairness and serves as
    cornerstone of understanding for millions of Americans seeking
    information, context and insight.
                         public funds for public media
        CPB is the primary public funding mechanism for public radio,
    accounting for roughly 12 percent of an average public radio station's
    annual budget. These funds help public broadcasting stations produce,
    purchase and distribute programming that sparks imagination and kindles
    thought about our world. Several stations specifically serve rural and
    minority communities including numerous African-American, Native
    American, Latino, and multicultural licensees. In many cases, they are
    the sole local broadcasting service available. These critical Federal
    funds allow all stations to continue serving the needs of public
    radio's 33 million weekly listeners, irrespective of their communities'
    location or financial status.
        CPB's general appropriation is allocated according to a
    congressionally set formula that ensures the funds go directly to the
    people and organizations that create and deliver highly valued programs
    and services. The public broadcasting community is urging Congress to
    appropriate $542 million in 2-year advanced funding for fiscal year
    2012 for CPB.
                       the public radio satellite system
        As the public broadcasting community grapples with the financial
    crisis, we also remain committed to ensuring that the Nation's public
    radio infrastructure continues to be robust and viable. This commitment
    requires a periodic investment by Congress in PRSS. This year, CPB is
    requesting $27 million as the third and final installment of a 3-year
    request to renew and replenish the PRSS.
        This system, originally built in 1979 with funds provided by this
    Committee, distributes 400,000 hours of programming, or 7\1/2\ billion
    listener hours each year. Every minute of every hour of public radio
    programming--from NPR's Morning Edition, and All Things Considered, to
    American Public Media's Marketplace and A Prairie Home Companion, to
    Public Radio International's This American Life and Capitol News
    Connection--is distributed by the PRSS. Quite simply, without the PRSS,
    there would be no public radio in the United States.
        An important mission of the PRSS is to facilitate the cost-
    effective and efficient distribution of news, information, cultural,
    and educational programming to this country's increasingly diverse
    population. As part of that mission, the PRSS provides satellite
    transmission services to distribute programming that targets unserved
    or underserved audiences from sources who meet certain criteria
    established by the NPR Board, including demonstrated financial need.
    PRSS is the indispensable distribution backbone for everything heard on
    public radio. On behalf of all in public radio, I ask for your support
    of this critically important funding request.
                           digital transition funding
        Change is rapidly occurring in over the air radio broadcasting, the
    last enclave of the old analogue world. As of today, more than 650
    public radio stations had either completed or have nearly completed
    conversion to a digital signal, which improves the overall listener
    experience by enhancing audio quality; eliminating reception
    interference; and utilizing multiple audio programming channels, or
    multicasting. To continue supporting this necessary change in our basic
    broadcast technology, CPB is requesting $40 million as part of its
    fiscal year 2010 budget.
        Digital broadcasting technology has enabled public radio stations
    to increase local services to their communities. More than 160 stations
    are multicasting--doubling and tripling their programming to broaden
    and expand the base of listeners. Many stations have created Spanish
    language channels to provide news, including through BBC Mundo.
    Stations serving Native American communities are providing tribal
    programming over the air and online. Local community events such as
    concerts, town hall meetings, committee hearings, legislative floor
    sessions, and other government programming are broadcast live using HD
    radio technology. Listeners with HD radio receivers may view a variety
    of useful messages that scroll across radio display screens, including
    artist name and song title, emergency alerts, live weather and real-
    time traffic updates, local news, school closings, and movie listings.
        Digital technology using the Internet and mobile platforms expands
    public radio programming and community services. Expansion and
    improvement of public radio Web sites and our digital connections with
    audiences remain a major priority. Public radio stations and public
    radio program producers are all expanding to new platforms, and in so
    doing bring broader, deeper and more varied content to our audiences.
    The impact is already being felt. News coverage of the U.S.
    Presidential election resulted in record level traffic to public radio
    station Web sites and NPR.org in terms of both visitors and page views.
    Ten million visitors went each month to NPR.org during October and
    November 2008 to view 115 million pages during the same time period.
    And just this past week, public radios web sites became an essential
    platform for updated information on Swine flu.
        Other Internet and mobile platform program distribution efforts
    using iPhone applications, for example, have gained wide acceptance
    among public radio listeners and brought a new generation of consumers
    to our coverage. Local public radio station and NPR podcasts have
    become very popular, with some 14 million downloads occurring each
    month. Podcasts offered by stations are expanding programming in areas
    such as science, poetry, music, arts, history, politics, international
    affairs, and health. The audience may also now download interactive
    media such as photo slide shows, video, Web streams and audio of local
    news, music, and programming on their local station Web site.
        Audiences are visiting station Web sites with greater frequency for
    local news and community events. Online community calendars posted on
    station Web sites allow local organizations of all sizes and areas to
    list public events and reach a wide audience. Listeners viewing station
    Web sites are connecting with local nonprofit organizations to obtain
    information about special cultural activities, festivals, public health
    fairs, musical events, educational seminars, lectures, classes, and
    workshops. Station Web sites also increasingly have online music play
    lists allowing the audience to find information on music played at
    their local station. Web-based social-networking features are used to
    foster online communities to give listeners the opportunity to connect
    over common interests and passions by engaging in dialogue and sharing
    viewpoints about their lives.
        We are confident in our ability to meet the needs of our audience
    and our ability to emerge from the current economic crisis more
    prepared and better structured. But we cannot do either without your
    help. We ask for your approval of CPB's funding requests, including the
    additional, emergency, one-time investment to stations of $307 million
    in fiscal year 2010.
                                     ______

            Prepared Statement of National Primate Research Centers
        The Directors of the eight National Primate Research Centers
    (NPRCs) respectfully submit this written testimony for the record to
    the Senate Appropriations Subcommittee on Labor, Health and Human
    Services, and Education, and Related Agencies. The NPRCs appreciate the
    commitment that the members of this subcommittee have made to
    biomedical research through your strong support for the National
    Institutes of Health (NIH), and recommends that you maintain this
    support for NIH in fiscal year 2010 by providing the agency with at
    least a 7 percent increase more than fiscal year 2009. The NPRCs also
    respectfully request that the subcommittee encourage the National
    Center for Research Resources (NCRR), the sponsoring institute of the
    NPRCs within NIH, to carry out the NPRCs 5-year Federal advancement
    initiative, which as explained in this testimony, would help to ensure
    that the NPRCs continue to serve effectively in their role as a vital
    national resource.
        Through passage of the American Recovery and Reinvestment Act
    (ARRA) and the Omnibus Appropriations Act for Fiscal Year 2009, the
    administration and Congress have taken critical steps to jump start the
    Nation's economy. Simultaneously, Congress is advancing and
    accelerating the biomedical research agenda in this country by focusing
    on scientific opportunities to address public health challenges. The
    success of the U.S. Government's efforts, however, is contingent upon
    the quality of research resources that enable and enhance scientific
    research ranging from the most basic and fundamental to the most highly
    applied.
        Biomedical researchers have relied on one such resource--NPRCs--for
    nearly 50 years for research models and expertise with nonhuman
    primates. The NPRCs are highly specialized facilities that foster the
    development of nonhuman primate animal models and provide expertise in
    all aspects of nonhuman primate biology. NPRC facilities and resources
    are currently used by more than 2,000 NIH-funded investigators around
    the country. NCRR provides the NPRCs with an annual base grant (funded
    through NCRR's P51 program) which supports the operational costs of the
    NPRCs. In fiscal year 2009, the 8 NPRCs received $79.235 million from
    NCRR's P51 program.
        The NPRCs also serve an essential role in translating basic
    research toward a clinical outcome. Specifically, the nonhuman primate
    models that are housed at the NPRCs often provide the critical link
    between research with small laboratory animals and studies involving
    humans. As a result, the network of the eight NPRCs is taking a
    leadership role to encourage collaboration among researchers and
    healthcare providers across disciplines and institutions, with the goal
    of advancing biomedical knowledge and improving human health.
        The NPRCs face several serious barriers to successfully supporting
    and advancing nonhuman primate research; specifically, the lack of
    adequate infrastructure to breed and house animals for research, the
    limited number of primates available, and the shortage of properly
    trained staff to handle nonhuman primates and provide sophisticated
    care. The need to address these problems has become even more critical
    due to the additional nonhuman-primate-related grants that will be
    funded as a result of ARRA, the new demands to increase research in
    nonhuman primate challenge models for AIDS, and the need for nonhuman
    primates to enhance our emerging infectious disease and biodefense
    response capabilities.
        NCRR has published on the need for increased primate resources in
    its 2009-2013 Strategic Plan. The plan specifically States that
    nonhuman animal models are indispensable for finding ways to treat and
    prevent cancer, HIV/AIDS, Alzheimer's disease, and Parkinson's disease,
    as well as to develop effective biodefense strategies. The NPRCs have
    been leading the development of new IT approaches, including the
    Biomedical Informatics Research Network (BIRN) for linking brain
    imaging, behavior, and molecular informatics in nonhuman primate
    preclinical and translational models research.
        In an effort to address many of the concerns within the scientific
    community, ranging from the lack of infrastructure improvements to the
    shortage of relevant nonhuman primates to the need for quality, trained
    personnel, the NPRCs have developed a 5-year Federal advancement
    initiative which addresses the necessary program capacity expansions
    and required upgrades. This initiative will help to ensure that the
    NPRCs will continue to serve effectively in their role as a vital
    national resource. As part of the 5-year plan development process, the
    NPRCs calculated the increases in NIH funding dedicated specifically to
    the National Primate Research Centers Program (NCRR's P51 program)
    necessary to achieve their goals. Below is an outline of the plan:
      --Primate Infrastructure Investment.--Request for an additional $90
            million over 5 years to improve the quality and capacity of
            primate housing and breeding facilities and ensure availability
            of related state-of-the-art diagnostic and clinical support
            equipment at the NPRCs.
        While NIH has been responsive in their actions during the past few
    years to provide funding to the NPRCs for infrastructure improvements,
    the difficulty the National Primate Research Centers Program has in
    meeting even current demands, let alone future increases is inexorably
    linked to the ability to house these animals in the unique living
    environments that they require and to provide specialized facilities
    equipped with state-of-the-art diagnostic and clinical support
    equipment to conduct research. The NPRCs plan to focus on the following
    goals in their effort to comprehensively improve primate
    infrastructure:
      --Bring older primate housing facilities and related equipment up to
            present-day standards.
      --Construct additional primate housing facilities and acquire related
            equipment to accommodate the projected increase in breeding
            colonies.
      --Primate Model Investment.--Request for an additional $75 million
            over 5 years to enhance the availability of primates for
            research.
        NCRR's Expert Panels have repeatedly stated that the NPRCs do not
    have the capacity to satisfy the needs of outside investigators, and
    have recommended that the NPRCs program must be responsive to national
    needs for nonhuman primates. Currently, outside investigators who are
    already funded for their studies must sometimes wait a year or more to
    begin their research because of the high demand for the limited number
    of primates. In addition, there are ongoing difficulties associated
    with acquiring certain types of primates from their natural places of
    origin. Accordingly, increasing domestic breeding capabilities and
    developing bridging programs to effectively use other types of primates
    are critical to the success of the NPRCs program.
      --Primate Care and Research Personnel Investment.--Request for an
            additional $35 million over 5 years to train NPRC personnel in
            primate care and management.
        Numerous scientific reports have highlighted the vital need for
    experts who are well-trained in laboratory animal medicine and in
    research methodology. Since nonhuman primates represent the most
    sophisticated and relevant animal models, there is a heightened
    responsibility to properly care for and manage these animals. Each NPRC
    requires a primate management team comprised of behaviorists,
    veterinarians, and primate research specialists. As the number of
    primates at the NPRCs grows, the primate management teams must expand
    proportionally.
        Total anticipated cost of the National Primate Research Centers
    Program 5-year Federal Advancement Initiative--$200 million more than
    the current funding that is dedicated specifically to the National
    Primate Research Centers Program during the 5-year period of fiscal
    years 2010-2015.
        Thank you for the opportunity to submit this written testimony and
    for your attention to the critical need for primate research and
    enhancement of the NPRCs P51 base grant, as well as our recommendations
    concerning funding for NIH in the fiscal year 2010 Labor, Health and
    Human Services, and Education, and Related Agencies Appropriations
    bill.
                                     ______

              Prepared Statement of the National Sleep Foundation
                  summary of fiscal year 2010 recommendations
      --Provide $5 million in funding for sleep activities within the
            Community Health Promotion account within the Chronic Disease
            Program at the Centers for Disease Control and Prevention
            (CDC). Expanded funding for sleep and sleep disorder-related
            activities would allow the CDC to create targeted public
            educational initiatives for schools and workplaces; training
            materials for current and future health professionals; build
            and test public health interventions; expand surveillance and
            epidemiological activities; and create fellowship and research
            opportunities.
      --Encourage the National Institutes of Health (NIH) to conduct multi-
            center clinical trials to evaluate whether healthcare costs and
            the incidence of stroke, cardiovascular disease and diabetes
            can be reduced by treating sleep disorders such as obstructive
            sleep apnea as part of usual care practices.
        Mr. Chairman and members of the subcommittee, thank you for
    allowing me to submit testimony on behalf of the National Sleep
    Foundation (NSF). I am Dr. Frankie Roman, Chair of the NSF's Government
    Affairs Committee and a sleep specialist at Ohio Sleep Disorder
    Centers, in Akron, Ohio. NSF is an independent, nonprofit organization
    that is dedicated to improving public health and safety by achieving
    understanding of sleep and sleep disorders, and by supporting sleep-
    related education, research and advocacy. We work with sleep medicine
    and other healthcare professionals, researchers, patients and drowsy
    driving advocates throughout the country as well as collaborate with
    many Government, public and professional organizations with the goal of
    preventing health and safety problems related to sleep deprivation and
    untreated sleep disorders.
        Sleep problems, whether in the form of medical disorders or related
    to work schedules and a 24/7 lifestyle, are ubiquitous in our society.
    It is estimated that sleep-related problems affect 50 to 70 million
    Americans of all ages and socioeconomic classes. Sleep disorders are
    common in both men and women; however, important disparities in
    prevalence and severity of certain sleep disorders have been identified
    in minorities and underserved populations. Despite the high prevalence
    of sleep disorders, the overwhelming majority of sufferers remain
    undiagnosed and untreated, creating unnecessary public health and
    safety problems, as well as increased health care expenses. Annual
    surveys conducted by NSF show that more than 60 percent of adults have
    never been asked about the quality of their sleep by a physician, and
    fewer than 20 percent--have ever initiated such a discussion.
        Additionally, Americans are chronically sleep deprived as a result
    of demanding lifestyles and a lack of education about the impact of
    sleep loss. Sleepiness affects vigilance, reaction times, learning
    abilities, alertness, mood, hand-eye coordination, and the accuracy of
    short-term memory. Sleepiness has been identified as the cause of a
    growing number of on-the-job accidents, automobile crashes and multi-
    model transportation tragedies.
        According to the National Highway Traffic Safety Administration's
    2002 National Survey of Distracted and Drowsy Driving Attitudes and
    Behaviors, an estimated 1.35 million drivers have been involved in a
    drowsy driving crash in the previous 5 years. According to NSF's 2009
    Sleep in America poll, 54 percent of people report that they have
    driven drowsy at least once in the past year, with 28 percent reporting
    that they do so at least once a month or more. A large number of
    academic studies and Government reports have linked lost productivity,
    poor school performance, and major public health problems to chronic
    sleep loss and sleep disorders.
        The 2006 Institute of Medicine (IOM) report, Sleep Disorders and
    Sleep Deprivation: An Unmet Public Health Problem, found the cumulative
    effects of sleep loss and sleep disorders represent an under-recognized
    public health problem and have been associated with a wide range of
    negative health consequences, including hypertension, diabetes,
    depression, heart attack, stroke, and at-risk behaviors such as alcohol
    and drug abuse--all of which represent long-term targets of the
    Department of Health and Human Services (HHS) and other public health
    agencies. Moreover, the personal and national economic impact is
    staggering. The IOM estimates that the direct and indirect costs
    associated with sleep disorders and sleep deprivation total hundreds of
    billions of dollars annually.
        Sleep science and Federal reports have clearly detailed the
    importance of sleep to health, safety, productivity and well-being, yet
    studies continue to show that millions of Americans remain at risk for
    serious health and safety consequences of untreated sleep disorders and
    inadequate sleep, due to a lack of awareness, community interventions,
    and inadequate screening. Unfortunately, despite recommendations in
    numerous Federal reports, there is a lack of epidemiological data,
    large clinical trials and no on-going national educational programs
    regarding sleep issues aimed at the general public, healthcare
    professionals, underserved communities or major at-risk groups.
        NSF believes that every American needs to understand that good
    health includes healthy sleep, just as it includes regular exercise and
    balanced nutrition. Sleep must be elevated to the top of the national
    health agenda in order to adequately address other national public
    health problems mentioned above. We need your help to make this happen.
        First, one of the most devastating sleep disorders is obstructive
    sleep apnea (OSA), a sleep-related breathing disorder which affects at
    least 5 percent of adult Americans and is closely related to some of
    America's most pressing health problems, such as obesity, hypertension,
    heart failure, and diabetes. NSF and its partners, including the
    National Center on Sleep Disorders Research at the National Institutes
    of Health, have been working diligently to create better patient and
    primary care physician awareness of sleep apnea. However, despite
    considerable progress, sleep apnea remains woefully underdiagnosed and
    undertreated primarily due to a lack of understanding in the primary
    care community, good epidemiological data, and randomized evidence
    regarding long-term treatment. Therefore, we recommend that the NIH be
    encouraged to conduct multi-center clinical trials to evaluate whether
    treatment of OSA can reduce healthcare costs and the incidence of
    stroke, cardiovascular disease and diabetes.
        Second, our biggest challenge is bridging the gap between the
    established sleep science best practices and the level of knowledge
    about sleep held by healthcare practitioners, educators, employers, and
    the general public. Because resources are limited and the challenges
    great, we think creative and new partnerships are needed to fully
    develop sleep awareness, education and clinical training initiatives.
    Consequently, the NSF has spearheaded important initiatives to raise
    awareness of the importance of sleep to the health, safety, and well-
    being of the Nation. One of our most important partnerships in these
    efforts is with the Centers for Disease Control and Prevention (CDC).
        For the last 5 years, Congress has recommended that the CDC support
    activities related to sleep and sleep disorders. As a result, CDC's
    National Center for Chronic Disease Prevention and Health Promotion has
    been collaborating with NSF and more than 20 voluntary organizations
    and Federal agencies to form the National Sleep Awareness Roundtable
    (NSART), which was officially launched in March of 2007. Congress also
    provided specific funding for these efforts for the past 2 years.
        In fiscal year 2008, Congress provided $818,000 for activities
    related to sleep and sleep disorders, including CDC's participation in
    NSART and incorporating sleep-related questions into established CDC
    surveillance systems. With this funding, CDC included one core sleep
    question in its national data collection efforts in 2008 and has
    provided grants to eight States to include an optional sleep module in
    their data collection efforts through the Behavioral Risk Factor
    Surveillance System (BRFSS), which will occur in the summer of 2009.
    CDC also included one question in the Youth Risk Behavior Surveillance
    System (YRBSS). Of note, the YRBSS has already revealed that only one-
    third of high school students get 8 or more hours of sleep on an
    average school night, far below the recommended 9.25 hours. This new
    data will provide important information on the prevalence of sleep
    disorders and enable researchers to better address the complex
    interrelationship between sleep loss and comorbid conditions such as
    obesity, diabetes, depression, hypertension, and drug and alcohol
    abuse.
        Additionally, CDC and NSART participated in NSF's national public
    awareness initiatives including National Sleep Awareness Week and
    Drowsy Driving Prevention Week. CDC also launched its own Sleep and
    Sleep Disorders Web site, created a fellowship position to analyze
    sleep and chronic disease data, held a Sleep and Public Health Workshop
    at the CDC campus, and released a number of multi-media health
    marketing materials to promote better sleep.
        In fiscal year 2009, Congress provided $900,000 to the CDC for
    sleep activities. CDC plans to expand the number of States it is able
    to fund for BRFSS data collection and provide support for national
    public and professional awareness initiatives as well as activities of
    the National Sleep Awareness Roundtable.
        NSF and NSART have actively been involved in conducting outreach to
    public health officials and are currently working to develop a national
    action plan. This document will address ways to organize and implement
    effective public and professional awareness and education initiatives
    primarily aimed at the diagnosis and treatment of obstructive sleep
    apnea and the promotion of sleep as a healthy behavior. NSART is
    seeking to expand its membership by reaching out to new organizations
    and State and Federal agencies that are interested in raising awareness
    of sleep issues and implementing NSART initiatives.
        Although the CDC has taken initial steps to begin to consider how
    sleep affects public health issues, the agency needs additional
    resources to take appropriate actions, as recommended by the IOM and
    other governmental reports.
        Expanded funding for sleep and sleep disorder-related activities
    would allow the CDC to create much needed educational programs for
    schools and occupational settings and training materials for current
    and future health professionals; build and test public health
    interventions; expand surveillance and epidemiological activities; and
    create further fellowships and research opportunities. The following
    are detailed scenarios for various funding levels.
      --$2 million:
        --Expand Surveillance on BRFSS.--CDC could double the number of
                grants it provides to States to use the optional sleep
                module and include more core questions in the nationwide
                data collection through the Behavioral Risk Factor
                Surveillance System. CDC would also expand its
                participation in and funding of national public and
                professional initiatives as well as the goals and
                activities of the National Sleep Awareness Roundtable.
      --$5 million--All activities detailed in the $2 million scenario,
            plus:
        --Public Education.--CDC could support the development of a
                national sleep health communications campaign that use
                targeted approaches for delivering sleep-related messages,
                especially in public schools and workplaces. Currently, no
                such programs exist.
        --Training Materials.--Tools and programs could be developed for
                current and future health professionals, including school
                nurses, to promote sleep as a healthy behavior and increase
                the diagnosis and treatment of sleep disorders. Today, most
                health care professionals receive no such training, which
                increases the Nation's health burden.
        NSF and members of the National Sleep Awareness Roundtable believe
    that an ongoing partnership with CDC is critical to address the
    enormous public health impact of sleep and sleep disorders. We hope
    that the Committee will provide funding of $5,000,000 to the CDC to
    execute programs as outlined here.
        Thank you again for the opportunity to present you with this
    testimony.
                                     ______

      Prepared Statement of the National Technical Institute for the Deaf
        Mr. Chairman and members of the subcommittee: I am pleased to
    present the fiscal year 2010 budget request for NTID, 1 of 8 colleges
    of Rochester Institute of Technology (RIT), in Rochester, New York.
    Created by Congress, we provide university technical education, serving
    a total of 1,450 students, including 1,284 deaf and hard-of-hearing
    students from across the Nation and 166 hearing students. NTID students
    live, study, and socialize with more than 15,000 hearing students on
    the RIT campus.
        NTID has fulfilled our mission with distinction for 41 years.
                                 budget request
        This request details the importance of obtaining our full fiscal
    year 2010 request of $71,352,000. We ask for $65,952,000 for continuing
    operations and $5,400,000 for construction to replace aging mechanical
    systems as detailed below. The NTID and President's requests are:

                                                [In millions of dollars]
    ----------------------------------------------------------------------------------------------------------------
                                                                        Operations     Construction        Total
    ----------------------------------------------------------------------------------------------------------------
    NTID request....................................................          65,952           5,400          71,352
    President's request \1\.........................................          63,037           5,400          68,437
                                                                     -----------------------------------------------
          Difference................................................           2,915  ..............           2,915
    ----------------------------------------------------------------------------------------------------------------
    \1\ These numbers are our understanding of what the President will submit to Congress.

        We respectfully request your support of our full appropriation
    request. We do not request new operations funding for additional
    academic programs or headcount; instead, we commit to fund increases,
    if any, through reallocating resources. This commitment continues our
    history of funding changes through internal reallocation. From fiscal
    year 2003 through fiscal year 2007 we documented $6,200,000 in budget
    reductions, including the elimination of 49 headcounts, and increasing
    our revenues. These difficult savings allowed us to improve our
    programs and services while limiting our request for Federal support.
    As one example, we dramatically increased the number of captionists
    employed to deliver in-classroom speech-to-text real-time access
    services to students, without additional funding.
        We are proud of those cost savings and reallocations
    accomplishments.
        Our fiscal year 2010 operations request represents costs driven by
    personnel and health benefits, as well as payment for services provided
    by RIT that are subject to the same inflationary pressures. The
    significant enrollment increases detailed below add proportionally to
    anticipated costs. We do not ask for funds to address program
    modifications; we will reallocate to meet those needs.
                                   enrollment
        As we prepare to enter fiscal year 2010, we do so having attracted,
    in fiscal year 2009, the largest enrollment in our 41-year history.
    Truly a national program, NTID enrolls students from all 50 States.
    Current enrollment of 1,450; in the last 2 years our enrollment has
    increased by 200 students, an increase of 16 percent. For fiscal year
    2010, NTID anticipates maintaining or slightly increasing enrollment.
    Our 5-year enrollment history follows.

                                                               NTID ENROLLMENTS: FIVE-YEAR HISTORY
    --------------------------------------------------------------------------------------------------------------------------------------------------------
                                                         Deaf/Hard-of-Hearing students                              Hearing students
                                                    ---------------------------------------             ----------------------------------------
                      Fiscal year                                                             Subtotal   Interpreting                            Grand total
                                                      Undergrad     Grad RIT       MSSE                     program        MSSE       Subtotal
    --------------------------------------------------------------------------------------------------------------------------------------------------------
    2005...........................................        1,055           42           49        1,146           100           35          135        1,281
    2006...........................................        1,013           53           38        1,104           116           36          152        1,256
    2007...........................................        1,017           47           31        1,095           130           25          155        1,250
    2008...........................................        1,103           51           31        1,185           130           28          158        1,353
    2009...........................................        1,212           48           24        1,284           135           31          166        1,450
    --------------------------------------------------------------------------------------------------------------------------------------------------------

                            student accomplishments
        For our graduates, 95 percent have been placed in jobs commensurate
    with the level of their education (using the Bureau of Labor Statistics
    methodology). Of our fiscal year 2007 graduates (the most recent class
    for which numbers are available), 63 percent were employed in business
    and industry, 29 percent in education/nonprofits, and 8 percent in
    Government.
        Graduation from NTID has a significant, positive effect on earnings
    over a lifetime, and results in a noteworthy reduction in dependence on
    welfare programs. In fiscal year 2007, NTID, the Social Security
    Administration, and Cornell University examined approximately 13,000
    deaf and hard-of-hearing individuals who applied and attended NTID over
    our entire history. We learned NTID graduation has significant economic
    benefits. By age 50, deaf and hard-of-hearing baccalaureate graduates
    earned on average $6,021 more per year than those with associate
    degrees, who in turn earned $3,996 more per year on average than those
    who withdraw. Students who withdraw earned $4,329 more than those who
    were not admitted. Students who withdrew experienced twice the rate of
    unemployment as graduates.
        The same studies showed 78 percent of these individuals were
    receiving Supplemental Security Income (SSI) benefits at age 19, but
    when they were 50 years old, only 1 percent of graduates drew these
    benefits, while on average 19 percent of individuals who withdrew or
    were rejected for admission continued to participate in the SSI
    program. Graduates also accessed Social Security Disability Insurance
    (SSDI), an unemployment benefit, at far lesser rates than students who
    withdrew; by age 50, 34 percent of nongraduates were receiving SSDI,
    while only 22 percent of baccalaureate graduates were receiving them
    and only 27 percent of associate graduates were receiving them.
    Considering the reduced dependency on these Federal income support
    programs, the Federal investment in NTID returns significant societal
    dividends.
        NTID clearly makes a significant, positive difference in earnings,
    and in lives.
              new ``military veterans with hearing loss'' program
        In fiscal year 2010, NTID will establish the ``Military Veterans
    with Hearing Loss'' program to enroll veterans who have suffered
    significant hearing loss as a result of their military service.
    Recently returned veterans with hearing loss can earn bachelor or
    graduate-level degrees at RIT with access services--such as real-time
    captioning and notetaking in the classroom--from NTID. Our faculty and
    staff are experienced in helping those with sudden hearing loss, and we
    provide comprehensive services for those with hearing aids or cochlear
    implants.
        The access services provided at NTID are unparalleled. More than 50
    classroom captionists provide real-time captioning to students. More
    than 120 sign language interpreters support students who benefit from
    interpreting.
        As many as 10 veterans could be admitted each year, growing to 50
    veterans over time. (RIT also recently announced it will become a
    ``Yellow Ribbon'' institution.)
                                  construction
        For the past 3 years, NTID has informed Congress of on-going
    planning to replace the deteriorating 25 boilers and 23 chillers in
    individual buildings throughout the RIT campus. Existing heating,
    ventilation and air conditioning systems remain from the original
    campus construction more than 40 years ago. Although prudent in
    providing on-going maintenance, RIT/NTID reached a point where normal
    maintenance was no longer feasible and the decision was reached to
    replace the existing system with five new boilers and seven new
    chillers.
        All of the buildings and spaces devoted to NTID programs across the
    RIT campus are connected to this system. An analysis determined the
    square footage used by NTID in each building serviced by the new
    system, and the resulting proportion of the total expenses was
    allocated to NTID. That analysis showed that NTID buildings and other
    spaces utilized 15 percent of the total square footage. With a total
    project cost of $36,000,000, NTID is responsible for $5,400,000 (15
    percent) of the total cost, which we request for fiscal year 2010.
        In addition to discussions with Congress, this request has been
    discussed repeatedly over several years with the U.S. Department of
    Education (ED); presentations and facilities tours were provided during
    oversight visits to NTID. We understand that the President supports
    this request, and we ask that Congress also support this construction
    cost.
                                ntid background
    Academic Programs
        NTID offers high-quality, career-focused, associate degree programs
    preparing students for specific well-paying technical careers. A
    cooperative education component ties closely to high-demand employment
    opportunities. Expanding transfer associate degree programs better
    serve the higher achieving segment of our student population who seek
    bachelors and masters degrees in an increasingly demanding marketplace.
    These transfer programs provide seamless transition to baccalaureate
    studies in other colleges of NTID where we support students in
    baccalaureate programs with access services and tutoring. One of NTID's
    greatest strengths is our outstanding track record of assisting high-
    potential students gain admission to and graduate from the other
    colleges of RIT at rates that are better than their hearing peers.
    Research
        Our research program is guided and organized according to these
    general research areas: language and literacy, teaching and learning,
    sociocultural influences, career development, technology integration,
    and institutional research. All benefit the deaf and hard-of-hearing
    population.
    Outreach
        Extended outreach activities to junior/senior high school students,
    expand their horizons regarding a college education. We also serve
    other universities and postcollege adults.
    Student Life
        Our activities foster student leadership and community service, and
    provide opportunities to explore other educational interests.
                                    summary
        It is extremely important that our funding be provided at the full
    level requested as we continue our mission to prepare deaf and hard-of-
    hearing people to enter the workplace and society.
        Our alumni have demonstrated that they can achieve independence,
    contribute to society, earn a living, and live a satisfying life as a
    result of NTID. Research shows that NTID graduates over their lifetimes
    are employed at a much higher rates, earn substantially more (therefore
    paying significantly more in taxes), and participate at a much lower
    rate in Federal welfare programs than those who withdraw or who apply
    but do not attend NTID.
        We are hopeful that the members of the subcommittee will agree that
    NTID, with its long history of successful stewardship of Federal funds
    and outstanding educational record of service with deaf and hard-of-
    hearing people, remains deserving of your support and confidence.
                                     ______

             Letter From the National Union of Labor Investigators
        Dear Sir or Madam: Before the budget for the Department of Labor,
    Office of Labor-Management Standards (OLMS) is approved, please
    consider the 43 employees who were recently deemed ``unaffordable''
    because of budget shortfalls, and please consider the OLMS's re-
    organization in 2008, a reorganization that now seems morally
    reprehensible. ``Fiscal Year 2010 Budget Shortfalls and Solutions'' was
    presented to OLMS employees on May 8, 2009, and during that
    presentation Deputy Assistant Secretary Andrew Auerbach said that OLMS
    hired just about as many investigators as it could afford because OLMS
    had been criticized for leaving itself understaffed.
        The presentation went on to point out that approximately $4.5
    million cut from the OLMS budget would return OLMS to its 2003 staffing
    level, and that OLMS's mission would not be compromised because
    workload and productivity have remained (relatively) constant since
    2003. The presentation reported 260 full-time employees in fiscal year
    2003, and 303 full-time employees in fiscal year 2009. The result, we
    were told, is that 43 OLMS employees are no longer affordable.
        The tone taken during the presentation was that the result was
    unavoidable. However, OLMS's reorganization in 2008 moved all managers
    to a higher pay grade, and given the current budget shortfalls, and the
    speed with which the reorganization took place, it seems less like a
    move intended to improve OLMS's effectiveness, and more like a case of
    traders with inside information dumping stocks just before the company
    that issued them goes bankrupt. Managers at every level, and in every
    office, warned their investigators of potential budget cuts and of the
    affect they might have on OLMS, and yet management went forward with a
    reorganization that exacerbated OLMS's budget crisis.
        It seems that if an unaltered work load and unaffected productivity
    has been used to defend OLMS's $4.5 million budget cut, the same logic
    should be applied to the reorganization. If their job responsibilities
    have not changed since 2003, why were OLMS managers given a raise in
    pay and grade, and why haven't managers been returned to their 2003 GS
    levels in order to address the budget shortfall? If all OLMS management
    positions were returned to their 2003 pay grade, would (all) 43
    employees have become unaffordable?
        I appreciate your consideration of this matter.
                Sincerely,
                                                         Bennett Allen.
                                     ______

             Letter From the National Union of Labor Investigators
                                                          May 11, 2009.
    Hon. Tom Harkin,
    Chairman, Subcommittee on Labor, Health and Human Services, and
            Education, and Related Agencies,
    Washington, DC.
        Dear Subcommittee on Labor, Health and Human Services, and
    Education, and Related Agencies Members: The new budget is out and our
    agency, Office of Labor Management Standards (OLMS), within the
    Department of Labor suffered a severe reduction in our budget. On May
    8, 2009, all employees of OLMS were notified that 43 positions were
    deemed unaffordable by the Employment Standards Administration (ESA),
    which OLMS falls under. As of the same date, 20 employees were
    involuntarily transferred to other agencies. They have 5 days to agree
    to this or lose their job. Though it was repeated this was not a
    Reduction in Force (RIF), this is essentially what has occurred.
        Additionally, the remaining 23 employees/positions have not been
    identified. OLMS is represented by an independent union, created in
    1971, the National Union of Labor Investigators (NULI). Despite an
    official union request seeking documents regarding the reorganization,
    nothing has been provided to NULI that represents all bargaining unit
    employees. Anxiety runs high as OLMS employees cannot know whether they
    are one of the designated 23 employees, and whether they should
    immediately look for work.
        NULI cannot possibly negotiate the impact of a plan that they do
    not have and cannot obtain. OLMS has essentially ignored the collective
    bargaining agreement negotiated by OLMS and NULI; and the right of NULI
    as the sole and exclusive bargaining representative for all unit
    employees. Regardless of the political powers, reasonable notice is
    still warranted. Rights of working people should be respected.
        In 1959, the Labor Management Reporting and Disclosure Act was
    enacted to correct the abuses which had crept into labor and management
    which was revealed during the investigations of the McClellan
    Committee. The Secretary of Labor administers and enforces the act.
        Shortly after the election of President Obama, the AFL-CIO wrote a
    proposal entitled AFL-CIO 2008 Transition Project Recommendations for
    the Obama Administration: Regulations of Union Finances and Elections
    Under the Labor Management and Disclosure Act that was provided to the
    Obama-Biden Transition team. Their recommendations asked for immediate
    revocation of revisions made to union financial disclosures. This was
    essentially enacted. They recommended a scaling back of OLMS'
    enforcement efforts. This, too, was enacted.
        Additionally, the transition team evaluating the OLMS was headed by
    Deborah Greenfield, former AFL-CIO Associate General Counsel. Her first
    stop in that position was to OLMS. Ms. Greenfield was one of the
    attorney's suing OLMS on behalf of the AFL-CIO. According to a recent
    Washington Times article, Ms. Greenfield currently is in charge of the
    Department's Executive Secretariat's office, which handles much of the
    correspondence for Secretary Solis. This appears to be in violation of
    President Obama's pledge to the American public when he said:

        ``No political appointees in an Obama-Biden administration will be
    permitted to work on regulations or contracts directly and
    substantially related to their prior employer for two years.''

        OLMS is not a partisan issue; it is about protecting the money and
    the democratic rights of American workers who engage in legitimate
    union activity. We are the only agency, created by Congress, to oversee
    and protect the rights of union workers. Allowing the budget to pass as
    is, allows for the rights of American workers to be trampled on.
        The rationale and the statistics provided to justify the decrease
    in funding and reduction in staff are gravely misconstrued and
    misleading. The Secretary of Labor has now directed OLMS to reduce the
    number of staff back to the levels when union officers and employees
    rest assured that the Government could not closely monitor or oversee
    their actions. As a society we are aware that when the Government
    cannot monitor, oversee, or enforce Federal law, those affected by
    those laws are left susceptible to violations of the law. What does
    this mean? It simply means that hard-working Americans who are union
    members may be subjected to an increase of theft: theft of their hard-
    working union dues and theft of their right to democracy in their
    union.
        I understand that our economy is currently struggling and we all
    need to make sacrifices. Every other agency within the Department of
    Labor has seen an increase in funding, except ours. While I greatly
    applaud the Secretary's efforts to bring back enforcement in areas that
    have been sorely underfunded in recent years, it seems somewhat
    antithetical that the one area that protects a large portion of the
    America's workers are scaled back. Let's not hurt the American workers
    more by allowing their hard earned money to be misused or having their
    democratic rights within the union reduced.
        I write to you not only as an employee but as a union member as
    well. I urge the Subcommittee on Labor, Health and Human Services, and
    Education, and Related Agencies to ask for a full inquiry and
    accounting into the reasoning behind the reductions of the OLMS budget
    and who will truly benefit from the lack of enforcement. I also ask
    that prior to approving the budget to please educate yourself on the
    true role and purpose of OLMS.
        Union rights are human rights. Whether you are for or against labor
    unions, they are an essential component for any true democracy. Cutting
    funding will only make unions weaker by reducing the rank and file's
    faith in their union leadership.
        Thank you for you time and consideration.
                Sincerely,
                                                   Elizabeth Messenger.
                                     ______

             Prepared Statement of the National Wildlife Federation
        Mr. Chairman, members of the subcommittee, on behalf of the
    National Wildlife Federation (NWF), our Nation's largest conservation
    advocacy and education organization, and our more than 4 million
    members and supporters, I thank you for the opportunity to provide
    funding recommendations for the Department of Education, Department of
    Labor (DOL), and the Corporation for National and Community Service
    (CNCS).
        We believe that the overall Federal investment in environmental
    education and sustainability education programs nationwide--pennies per
    capita--is woefully inadequate. While NWF supports numerous programs
    under the jurisdiction of this subcommittee, the purpose of this
    testimony is to recommend levels of funding for specific sustainability
    education, green jobs education and training, and national service
    programs that we believe are vital to NWF's mission to inspire
    Americans to protect wildlife for our children's future. NWF also
    supports climate change education and environmental education programs
    across the Federal agencies at the U.S. Forest Service, Environmental
    Protection Agency, National Science Foundation, National Space and
    Atmospheric Administration, National Oceanic and Atmospheric
    Administration, and U.S. Department of the Interior.

                                               SUMMARY OF RECOMMENDATIONS
    ----------------------------------------------------------------------------------------------------------------
                                                                        Fiscal year 2010
                    Agency                         Program               recommendation       Fiscal year 2009 level
    ----------------------------------------------------------------------------------------------------------------
    Education............................  University               $50 million............  Not authorized in
                                            Sustainability Program.                           fiscal year 2009
    Education............................  Healthy High             $25 million............  None
                                            Performance Schools.
    Labor................................  Green Jobs Act.........  $125 million...........  Funded at $500 million
                                                                                              total in ARRA
    Labor................................  Community Based Jobs     $250 million--green      $125 million
                                            Training Grants.         prior-  ity.
    CNCS.................................  Clean Energy Service     $100 million...........  Not authorized in
                                            Corps.                                            fiscal year 2009
    ----------------------------------------------------------------------------------------------------------------

       the need for environmental education and sustainability education
        As our Nation moves towards a clean energy economy and creates new
    ``green jobs,'' we must ensure that our education and training
    infrastructure keeps pace. Congress and President Obama have stated
    their desire to cap global warming pollution this year, a priority that
    NWF strongly supports. To be successful as a Nation under a new cap and
    trade system, we must have an environmentally literate citizenry that
    has the knowledge and skills to find new and innovative solutions to
    protect our planet. While public awareness and concern about global
    warming continues to rise, the vast majority of the public does not
    understand how climate change works, how it impacts their lives and
    careers, and how their decisions and actions contribute to it. Consider
    the following examples:
      --Survey research shows that most Americans do not know what the
            carbon cycle is or understand what actually causes global
            warming. They do not know how most electricity is generated or
            the importance of healthy forests and oceans in generating
            oxygen and absorbing carbon dioxide.
      --Less than half of the population recognizes that the cars and
            appliances they use contribute to global warming, and 8 out of
            10 parents admit that they know ``little'' to ``nothing'' about
            the specific causes of climate change.
      --The average high school student fails a quiz on the causes and
            consequences of climate change (nearly 82 percent of
            participants affirmed, incorrectly, that ``scientists believe
            radiation from nuclear power plants cause global temperatures
            to rise'').
        Educating Americans about climate change is a huge opportunity for
    our Nation to prepare today's leaders, and the leaders of tomorrow, to
    implement the solutions created by a cap and trade system. Addressing
    global warming will generate millions of good new jobs and put the
    United States at the exciting forefront of a new clean energy economy.
    The successful transition to this new green economy hinges on education
    and training. This testimony focuses on key programs that educate and
    train Americans at institutions of higher education, through
    conservation corps programs that educate and train at-risk youth for
    careers in clean energy, and through green workforce education and
    training programs through the Department of Labor.
                            department of education
    University Sustainability Program (USP)
        The National Wildlife Federation supports funding the newly
    authorized USP at $50 million in fiscal year 2010. Interest in
    sustainability is exploding on college campuses across the Nation, and
    institutions are making remarkable changes to try to reduce campus
    carbon footprints and energy use. However, despite increasing interest
    and demand from students, sustainability education programs on college
    campuses are on the decline according to a comprehensive study released
    in August 2008 by NWF and Princeton Survey Research Associates
    International, called the ``Campus Environment 2008: A National Report
    Card on Sustainability in Higher Education.'' Environmental curriculum
    requirements are slipping and today's students may be less
    environmentally literate when they graduate than their predecessors.
        Congress authorized a new USP at the Department of Education as
    part U of the recently enacted Higher Education Opportunity Act of 2008
    (H.R. 4137). This program has the potential for high-impact, high-
    visibility, broad support within higher education, and is responsive to
    an important national trend in higher education. Sustainability on
    college campuses is critical, from education in the classroom to
    facility operations. Higher education produces almost all of the
    Nation's leaders in all sectors and endeavors, and many college
    campuses are virtually small cities in their size, environmental
    impact, and financial influence. Campuses use vast amounts of energy to
    heat, cool, and light their facilities. In all, the Nation's 4,100
    campuses educate or employ around 20 million individuals and generate
    more than 3 percent of the Nation's GDP. The economic clout of these
    schools is further multiplied by the hundreds of thousands of business
    suppliers, property owners, and other commercial and nonprofit entities
    involved with higher education. Funding for the newly authorized USP is
    critical to help provide difficult-to-get seed funding to launch
    sustainability education programs and to help support mainstream higher
    education associations in including sustainability in their work with
    their member institutions.
                    healthy high performance schools program
        The National Wildlife Federation supports funding the Healthy High
    Performance Schools Program at $25 million in fiscal year 2010. The
    Healthy High Performance Schools Program seeks to facilitate the
    design, construction and operation of high performance schools:
    environments that are not only energy and resource efficient, but also
    healthy, comfortable, well lit, and containing the amenities for a
    quality education. This grant program is critical at a time when energy
    costs for America's elementary and secondary schools are skyrocketing.
    The No Child Left Behind Act (Public Law 107-110, title 5, part D,
    subtitle 18) authorized grants to State education agencies to advance
    the development of ``healthy, high performance'' school buildings.
    States may use the funds to provide information, technical assistance,
    monitor, evaluate, and provide funding to local education agencies for
    healthy, high-performance school buildings. In turn, local agencies may
    use the funding to obtain technical assistance, develop plans that
    address reducing energy and meet health and safety codes, and conduct
    energy audits. Funds may not be used for construction, maintenance,
    repair or renovation of buildings. Research clearly shows that
    improving specific factors such as school indoor environmental quality
    improves attendance, academic performance, and productivity. This
    program has yet to be funded by Congress.
        NWF also supports a priority for funding green Career and Technical
    Education programs and initiatives at the Department of Education.
        While not yet authorized, NWF strongly supports authorization of
    and full funding at $100 million per year for the No Child Left Inside
    (NCLI) Act of 2009, which has the support of more than 1,300 national,
    State, and local organizations representing more than 45 million
    Americans. The central new policy in this legislation is the incentive
    for States to create or update a State Environmental Literacy Plan.
    Environmental Literacy Plans can be developed to meet the needs of each
    State and systemically advance environmental education through the K-12
    education system. These State plans support teacher training and
    professional development and support capacity building for
    environmental education. The House passed a modified version of the
    bill in the 110th Congress by a bipartisan vote of 293-109.
                              department of labor
        NWF supports a priority for green jobs education and training at
    the Department of Labor though the Workforce Investment Act Adult and
    Youth funding streams, the Energy Efficiency and Renewable Energy
    Worker Training Program, and the Community-Based Job Training program.
    Energy Efficiency and Renewable Energy Worker Training Program
        NWF supports funding the Energy Efficiency and Renewable Energy
    Worker Training Program at $125 million in fiscal year 2010. NWF
    greatly appreciates this subcommittee's first-time investment in Green
    Jobs Education and Training in the recent American Recovery and
    Reinvestment Act (ARRA). This unprecedented investment will help
    jumpstart the education and training needed to prepare Americans for
    the clean energy economy. We hope that the subcommittee will fund The
    Green Jobs Act (GJA), title X of the Energy Independence and Security
    Act, which authorizes $125 million per year in grants for an Energy
    Efficiency and Renewable Energy Worker Training Program. NWF is seeking
    $125 million in this fiscal year 2010 bill, recognizing that the
    subcommittee will assess how the investment through ARRA is spent
    before making new funding available. NWF believes it is important to
    make annual investments in this program through the regular
    appropriations process, in addition to necessary infusions of funding
    through stimulus and supplemental bills. This program identifies needed
    skills, develops training programs, and trains workers for jobs in a
    range of green industries, but has a special focus on creating ``green
    pathways out of poverty.'' The program is administered by the
    Department of Labor in consultation with the Department of Energy. ARRA
    responds to already existing skill shortages. The National Renewable
    Energy Lab has identified a shortage of skills and training as a
    leading barrier to renewable energy and energy efficiency growth. This
    labor shortage is only likely to get more severe as baby-boomers
    skilled in current energy technologies retire; in the power sector, for
    example, nearly one-quarter of the current workforce will be eligible
    for retirement in the next 5 to 7 years.
    Community-Based Job Training Grants Program
        NWF supports funding the Community-Based Job Training Grants
    Program at $250 million in fiscal year 2010. NWF believes that
    community colleges are critical partners in training and educating the
    next generation of Americans for green jobs. NWF supports a priority
    within this program for green jobs education and training grants. The
    Community-Based Job Training Grants program supports partnerships of
    community colleges, business, and workforce investment boards seeking
    to train workers for high-demand occupations. These competitive grants
    help ensure that efforts funded through the program are well
    coordinated with other local and regional workforce development
    efforts. Community-Based Job Training Grants support workforce training
    for high-growth industries through the Nation's community and technical
    colleges. Their primary purpose is to build community colleges'
    capacity to equip workers with the skills required to succeed in local
    industries.
                 corporation for national and community service
    Clean Energy Service Corps
        NWF supports funding the Clean Energy Service Corps at $100 million
    in fiscal year 2010. The Clean Energy Service Corps, building on the
    legacy of the depression-era Civilian Conservation Corps and modeled
    after today's Service and Conservation Corps, will address the Nation's
    energy and environmental needs while providing work and service
    opportunities, especially for disadvantaged youth ages 16-25. In a
    manner similar to the Civilian Conservation Corps of the 1930s,
    disconnected young people may be mobilized through this program to
    retrofit, weatherize, and otherwise improve the energy efficiency of
    residential and public facilities that account for more than 40 percent
    of carbon emissions. Specific projects that are authorized include
    weatherizing and retrofitting housing units for low-income households,
    cleaning and improving rivers, and working with schools and youth
    programs to educate students and youth about ways to reduce home energy
    use and improve the environment.
                                   conclusion
        Providing Federal support for environmental education,
    sustainability education, green jobs education and training, and green
    national service programs is critical for securing our new clean energy
    future and preparing the next generation for the challenges and
    opportunities ahead.
                                     ______

           Prepared Statement of the Ovarian Cancer National Alliance
        On behalf of the Ovarian Cancer National Alliance (the Alliance),
    thank you for this opportunity to submit comments for the record
    regarding the Alliance's fiscal year 2010 funding recommendations. We
    believe these recommendations are critical to ensure advances to help
    reduce and prevent suffering from ovarian cancer. For 12 years, the
    Alliance has worked to increase awareness of ovarian cancer and
    advocated for additional Federal resources to support research that
    would lead to more effective diagnostics and treatments.
        As an umbrella organization with 45 State and local organizations,
    the Alliance unites the efforts of survivors, grassroots activists,
    women's health advocates, and healthcare professionals to bring
    national attention to ovarian cancer. Our sole mission is to conquer
    ovarian cancer.
        According to the American Cancer Society, in 2008, more than 22,000
    American women were diagnosed with ovarian cancer and approximately
    15,000 lost their lives to this terrible disease. Ovarian cancer is the
    fifth leading cause of cancer death in women. Currently, more than half
    of the women diagnosed with ovarian cancer will die within 5 years.
    While ovarian cancer has early symptoms, there is no early detection
    test. Most women are diagnosed in stage III or stage IV, when survival
    rates are low. If diagnosed early, more than 90 percent of women will
    survive for 5 years, but when diagnosed later, less than 30 percent
    will.
        In addition, only a few treatments have been approved by the Food
    and Drug Administration for ovarian cancer treatment. These are
    platinum-based therapies and women needing further rounds of treatment
    are frequently resistant to them. More than 70 percent of ovarian
    cancer patients will have a recurrence at some point, underlying the
    need for treatments to which patients do not grow resistant.
        For all of these problems, we urgently call on Congress to
    appropriate funds to find solutions.
        As part of this effort, the Alliance advocates for continued
    Federal investment in the Centers for Disease Control and Prevention's
    (CDC) Ovarian Cancer Control Initiative. The Alliance respectfully
    requests that Congress provide $10 million for the program in fiscal
    year 2010.
        The Alliance also fully supports Congress in taking action on
    ovarian cancer through its recent passage of Johanna's Law: The
    Gynecologic Cancer Education and Awareness Act (Public Law 109-475).
    The Alliance respectfully requests that Congress provide $10 million to
    implement Johanna's Law in fiscal year 2010.
        Further, the Alliance urges Congress to continue funding the
    Specialized Programs of Research Excellence (SPOREs), including the
    four ovarian cancer sites. These programs are administered through the
    National Cancer Institute (NCI) of the National Institutes of Health
    (NIH). The Alliance respectfully requests that Congress provide $6
    billion to NCI for fiscal year 2010.
                                      cdc
    The Ovarian Cancer Control Initiative
        As the statistics indicate, late detection and, therefore, poor
    survival are among the most urgent challenges we face in the ovarian
    cancer field. The CDC's cancer program, with its strong capacity in
    epidemiology and excellent track record in public and professional
    education, is well-positioned to address these problems. As the
    Nation's leading prevention agency, the CDC plays an important role in
    translating and delivering at the community level what is learned from
    research, especially ensuring that those populations disproportionately
    affected by cancer receive the benefits of our Nation's investment in
    medical research.
        Prompted by efforts from leaders of the Alliance and championed by
    Representative Rosa DeLauro--with bipartisan, bicameral support--
    Congress established the Ovarian Cancer Control Initiative at the CDC
    in November 1999. Congress' directive to the agency was to develop an
    appropriate public health response to ovarian cancer and conduct
    several public health activities targeted toward reducing ovarian
    cancer morbidity and mortality.
        Through the OCCI, the National Comprehensive Cancer Control Program
    is helping States address issues related to ovarian cancer. The program
    currently funds efforts in California, Florida, Michigan, New York,
    Pennsylvania, Texas, and West Virginia. These projects are working to
    develop ovarian cancer health messages for the general public and for
    healthcare providers.
       johanna's law: the gynecologic cancer education and awareness act
        It is critical for women and their healthcare providers to be aware
    of the signs, symptoms and risk factors of ovarian and other
    gynecologic cancers. Often, women and providers mistakenly confuse
    ovarian cancer signs and symptoms with those of gastrointestinal
    disorders or early menopause. While symptoms may seem vague--bloating,
    pelvic or abdominal pain, increased abdominal size and bloating and
    difficulty, eating or feeling full quickly, or urinary symptoms
    (urgency or frequency)--they can be deadly without proper medical
    intervention.
        In recognition of the need for awareness and education, Congress
    unanimously passed Johanna's Law in 2006, enacted in early 2007. This
    law provides for an education and awareness campaign that will increase
    providers' and women's awareness of all gynecologic cancers including
    ovarian. Together, Johanna's Law and the Ovarian Cancer Control
    Initiative will help increase awareness and understanding of ovarian
    cancer and work to reduce ovarian cancer morbidity and mortality.
        Already, with only a small amount of seed money, the CDC has
    launched the Inside Knowledge: Get the Facts About Gynecologic Cancer
    campaign to raise awareness of the five main types of gynecologic
    cancer: ovarian, cervical, uterine, vaginal, and vulvar. Many fact
    sheets, including the ovarian cancer fact sheet, are already available
    on the CDC's Web site for download. The CDC plans to develop broadcast
    advertisements, posters--such as dioramas for bus stops--and other
    print materials, a comprehensive brochure on gynecologic cancers, and
    materials aimed at healthcare providers.
                                      nci
    SPOREs at NIH
        The Specialized Programs of Research Excellence were created by the
    NCI in 1992 to support translational, organ site-focused cancer
    research. The ovarian cancer SPOREs began in 1999. There are four
    currently funded Ovarian Cancer SPOREs located at the MD Anderson
    Cancer Center, the Fred Hutchinson Cancer Research Center, the Fox
    Chase Cancer Center and the Dana Farber/Harvard Cancer Center.
        These SPORE programs have made outstanding strides in understanding
    ovarian cancer, as illustrated by their more than 300 publications as
    well as other notable achievements, including the development of an
    infrastructure between Ovarian SPORE institutions to facilitate
    collaborative studies on understanding, early detection, and treatment
    of ovarian cancer.
    Clinical Trials
        NCI supports clinical research--the only way to test the safety and
    efficacy of potential new treatments for ovarian cancer. Two recent
    studies from NCI clinical trials show the impact of intraperitoneal
    chemotherapy in treating ovarian cancer (when chemotherapy is
    introduced directly into the woman's abdominal cavity, rather than her
    bloodstream) and the importance of ultrasound expertise in properly
    diagnosing the disease.
        NCI supports the Gynecology Oncology Group (GOG), a more than 50-
    member collaborative focusing on cancers of the female reproductive
    system. In 2007 alone, GOG published 23 articles about ovarian cancer.
                                    summary
        The Alliance maintains a long-standing commitment to work with
    Congress, the administration, and other policy makers and stakeholders
    to improve the survival rate for women with ovarian cancer through
    education, public policy, research, and communication. Please know we
    appreciate and understand that our Nation faces many challenges and
    Congress has limited resources to allocate; however, we are concerned
    that without increased funding to bolster and expand ovarian cancer
    education, awareness and research efforts, the Nation will continue to
    see growing numbers of women losing their battle with this terrible
    disease.
        On behalf of the entire ovarian cancer community--patients, family
    members, clinicians, and researchers--we thank you for your leadership
    and support of Federal programs that seek to reduce and prevent
    suffering from ovarian cancer. Thank you in advance for your support of
    $10 million in fiscal year 2010 funding for the CDC's Ovarian Cancer
    Control Initiative and $10 million in fiscal year 2010 funding for
    Johanna's Law as well as your continued support of the SPORES program,
    an appropriation of $6 billion to NCI.
                                     ______

               Prepared Statement of the Oncology Nursing Society
                                    overview
        The Oncology Nursing Society (ONS) appreciates the opportunity to
    submit written comments for the record regarding fiscal year 2010
    funding for cancer and nursing-related programs. ONS, the largest
    professional oncology group in the United States, composed of more than
    37,000 nurses and other health professionals, exists to promote
    excellence in oncology nursing and the provision of quality care to
    those individuals affected by cancer. As part of its mission, ONS
    honors and maintains nursing's historical and essential commitment to
    advocacy for the public good.
        In 2009, an estimated 1.44 million Americans will be diagnosed with
    cancer, and more than 565,650 will lose their battle with this terrible
    disease; at the same time the national nursing shortage is expected to
    worsen. Overall, age is the number one risk factor for developing
    cancer. Approximately 77 percent of all cancers are diagnosed at age 55
    and older.\1\ Despite these grim statistics, significant gains in the
    war against cancer have been made through our Nation's investment in
    cancer research and its application. Research holds the key to improved
    cancer prevention, early detection, diagnosis, and treatment, but such
    breakthroughs are meaningless, unless we can deliver them to all
    Americans in need. Moreover, a recent survey of ONS members found that
    the nursing shortage is having an adverse impact in oncology physician
    offices and hospital outpatient departments. Some respondents indicated
    that when a nurse leaves their practice, they are unable to hire a
    replacement due to the shortage--leaving them short-staffed and posing
    scheduling challenges for the practice and the patients. These
    vacancies in all care settings create significant barriers to ensuring
    access to quality care.
    ---------------------------------------------------------------------------
        \1\ American Cancer Society. Cancer Facts and Figures 2008. http://
    www.cancer.org/downloads/STT/2008CAFFfinalsecured.pdf.
    ---------------------------------------------------------------------------
        To ensure that all people with cancer have access to the
    comprehensive, quality care they need and deserve, ONS advocates
    ongoing and significant Federal funding for cancer research and
    application, as well as funding for programs that help ensure an
    adequate oncology nursing workforce to care for people with cancer. ONS
    stands ready to work with policymakers at the local, State, and Federal
    levels to advance policies and programs that will reduce and prevent
    suffering from cancer and sustain and strengthen the Nation's nursing
    workforce. We thank the subcommittee for its consideration of our
    fiscal year 2010 funding request detailed below.
        securing and maintaining an adequate oncology nursing workforce
        Oncology nurses are on the front lines in the provision of quality
    cancer care for individuals with cancer--administering chemotherapy,
    managing patient therapies and side effects, working with insurance
    companies to ensure that patients receive the appropriate treatment,
    providing treatment education and counseling to patients and family
    members, and engaging in myriad other activities on behalf of people
    with cancer and their families. Cancer is a complex, multifaceted
    chronic disease, and people with cancer require specialty-nursing
    interventions at every step of the cancer experience. People with
    cancer are best served by nurses specialized in oncology care, who are
    certified in that specialty.
        As the overall number of nurses is expected to drop precipitously
    in the coming years, we likely will experience a commensurate decrease
    in the number of nurses trained in the specialty of oncology. With an
    increasing number of people with cancer needing high-quality
    healthcare, coupled with an inadequate nursing workforce, our Nation
    could quickly face a cancer care crisis of serious proportion, with
    limited access to quality cancer care, particularly in traditionally
    underserved areas. A study in the New England Journal of Medicine found
    that nursing shortages in hospitals are associated with a higher risk
    of complications--such as urinary tract infections and pneumonia,
    longer hospital stays, and even patient death.\2\ Without an adequate
    supply of nurses, there will not be enough qualified oncology nurses to
    provide the quality cancer care to a growing population of people in
    need, and patient health and well-being could suffer.
    ---------------------------------------------------------------------------
        \2\ Needleman J., Buerhaus P., Mattke S., Stewart M., Zelevinsky K.
    ``Nurse-Staffing Levels and the Quality of Care in Hospitals.'' New
    England Journal of Medicine 346:, (May 30, 2002): 1715-1722.
    ---------------------------------------------------------------------------
        Of additional concern is that our Nation also will face a shortage
    of nurses available and able to conduct cancer research and clinical
    trials. With a shortage of cancer research nurses, progress against
    cancer will take longer because of scarce human resources coupled with
    the reality that some practices and cancer centers' resources could be
    funneled away from cancer research to pay for the hiring and retention
    of oncology nurses to provide direct patient care. Without a sufficient
    supply of trained, educated, and experienced oncology nurses, we are
    concerned that our Nation may falter in its delivery and application of
    the benefits from our Federal investment in research.
        ONS has joins with President Obama and others in the nursing
    community in advocating $263 million as the fiscal year 2010 funding
    level necessary to support implementation of the Nurse Reinvestment Act
    and the range of nursing workforce development programs housed at the
    U.S. Health Resources and Services Administration (HRSA). Enacted in
    2002, the Nurse Reinvestment Act (Public Law 107-205) included new and
    expanded initiatives, including loan forgiveness, scholarships, career
    ladder opportunities, and public service announcements to advance
    nursing as a career. Despite the enactment of this critical measure,
    HRSA fails to have the resources necessary to meet the current and
    growing demands for our Nation's nursing workforce. For example, in
    fiscal year 2008 HRSA received 6,078 applications for the Nurse
    Education Loan Repayment Program, but only had the funds to award 435
    of those applications.\3\ Also, in fiscal year 2008 HRSA received 4,894
    applications for the Nursing Scholarship Program, but only had funding
    to support 172 awards.\4\
    ---------------------------------------------------------------------------
        \3\ U.S. Health Resources and Services Administration: Nurse
    Education Loan Repayment Program: http://bhpr.hrsa.gov/nursing/
    loanrepay.htm. Accessed April 22, 2009.
        \4\ U.S. Health Resources and Services Administration: Nursing
    Scholarship Program Statistics: http://bhpr.hrsa.gov/nursing/
    scholarship/. Accessed April 22, 2009.
    ---------------------------------------------------------------------------
        A number of years ago, one of the biggest factors associated with
    the shortage was a lack of interested and qualified applicants. Due to
    the efforts of ONS, our nursing community partners, and other
    interested stakeholders, the number of applicants is growing. As such,
    now one of the greatest factors contributing to the shortage is that
    nursing programs are turning away qualified applicants to entry-level
    baccalaureate programs, due to a shortage of nursing faculty. According
    to the American Association of Colleges of Nursing (AACN), U.S. nursing
    schools turned away 50,000 qualified applicants from baccalaureate and
    graduate nursing programs in 2008, due to insufficient number of
    faculty and inadequate resources.\5\ Of those potential students,
    nearly 7,000 were students pursuing a master's or doctoral degree in
    nursing, which is the education level required to teach. Within the
    next decade, it is expected that half of all nurse faculty will reach
    retirement age.\6\ Given the expected wave of retirement among faculty,
    the nurse faculty shortage is only expected to worsen as there are
    insufficient numbers of candidates in the pipeline to take their
    places. The number of full-time nursing faculty required to ``fill the
    nursing gap'' is approximately 40,000, and, currently, there are less
    than 20,000 full-time nursing faculty in the system.
    ---------------------------------------------------------------------------
        \5\ American Association of Colleges of Nursing ,``2006-2007
    Enrollment and Graduations in Baccalaureate and Graduate Programs in
    Nursing.'' http://www.aacn.nche.edu/IDS/datarep.htm, March 2007.
        \6\ Preliminary Results: ``National Survey of Nurse Educators:
    Compensation, Workload, and Teaching Practices.'' National League of
    Nursing/Carnegie Foundation. (February 7, 2007) http://www.nln.org/
    newsreleases/pres_budget2007.htm.
    ---------------------------------------------------------------------------
        With additional funding in fiscal year 2010, the HRSA Workforce
    Development Programs will have much-needed resources to address the
    multiple factors contributing to the nationwide nursing shortage,
    including the shortage of faculty. Advanced nursing education programs
    play an integral role in supporting registered nurses interested in
    advancing in their practice and becoming faculty. As such, these
    programs must be adequately funded in the coming year.
        ONS strongly urges Congress to provide HRSA with a minimum of $263
    million in fiscal year 2010 to ensure that the agency has the resources
    necessary to fund a higher rate of nursing scholarships and loan
    repayment applications and support other essential endeavors to sustain
    and boost our Nation's nursing workforce. Nurses--along with patients,
    family members, hospitals, and others--have joined together in calling
    upon Congress to provide this essential level of funding. ONS and its
    allies have serious concerns that without full funding, the Nurse
    Reinvestment Act will prove an empty promise, and the current and
    expected nursing shortage will worsen, and people will not have access
    to the quality care they need and deserve.
                sustain and seize cancer research opportunities
        Our Nation has benefited immensely from past Federal investment in
    biomedical research at the National Institutes of Health (NIH). ONS has
    joined with the broader health community in advocating a 10 percent
    increase ($33.349 billion) for NIH in fiscal year 2010. This level of
    investment will allow NIH to sustain and build on its research
    progress, while avoiding the severe disruption to advancement that
    could result from a minimal increase. Cancer research is producing
    amazing breakthroughs--leading to new therapies that translate into
    longer survival and improved quality of life for cancer patients. In
    recent years, we have seen extraordinary advances in cancer research,
    resulting from our national investment, which have produced effective
    prevention, early detection, and treatment methods for many cancers. To
    that end, ONS calls upon Congress to allocate $5.957 billion to the
    National Cancer Institute, as well as $227 million to the National
    Center for Minority Health and Health Disparities in fiscal year 2010
    to support the battle against cancer.
        The National Institute of Nursing Research (NINR) supports basic
    and clinical research to establish a scientific basis for the care of
    individuals across the life span--from management of patients during
    illness and recovery, to the reduction of risks for disease and
    disability and the promotion of healthy lifestyles. These efforts are
    crucial in translating scientific advances into cost-effective
    healthcare that does not compromise quality of care for patients.
    Additionally, NINR fosters collaborations with many other disciplines
    in areas of mutual interest, such as long-term care for older people,
    the special needs of women across the life span, bioethical issues
    associated with genetic testing and counseling, and the impact of
    environmental influences on risk factors for chronic illnesses, such as
    cancer. ONS joins with others in the nursing community and NCCR in
    advocating a fiscal year 2010 allocation of $178 million for NINR.
     boost our nation's investment in cancer prevention, early detection,
                                 and awareness
        Approximately two-thirds of cancer cases are preventable through
    lifestyle and behavioral factors and improved practice of cancer
    screening. Although the potential for reducing the human, economic, and
    social costs of cancer by focusing on prevention and early detection
    efforts remains great, our Nation does not invest sufficiently in these
    strategies. The Nation must make significant and unprecedented Federal
    investments today to address the burden of cancer and other chronic
    diseases, and to reduce the demand on the healthcare system and
    diminish suffering in our Nation, both for today and tomorrow.
        As the Nation's leading prevention agency, the Centers for Disease
    Control and Prevention (CDC) plays an important role in translating and
    delivering, at the community level, what is learned from research.
    Therefore, ONS joins with our partners in the cancer community in
    calling on Congress to provide additional resources for the CDC to
    support and expand much-needed and proven effective cancer prevention,
    early detection, and risk reduction efforts. Specifically, ONS
    advocates the following fiscal year 2010 funding levels for the
    following CDC programs:
      --$250 million for the National Breast and Cervical Cancer Early
            Detection Program;
      --$65 million for the National Cancer Registries Program;
      --$25 million for the Colorectal Cancer Prevention and Control
            Initiative;
      --$50 million for the Comprehensive Cancer Control Initiative;
      --$25 million for the Prostate Cancer Control Initiative;
      --$5 million for the National Skin Cancer Prevention Education
            Program;
      --$10 million for the Ovarian Cancer Control Initiative; and
      --$6 million for the Geraldine Ferraro Blood Cancer Program.
                                   conclusion
        ONS maintains a strong commitment to working with Members of
    Congress, other nursing and oncology societies, patient organizations,
    and other stakeholders to ensure that the oncology nurses of today
    continue to practice tomorrow, and that we recruit and retain new
    oncology nurses to meet the unfortunate growing demand that we will
    face in the coming years. By providing the fiscal year 2010 funding
    levels detailed above, we believe the subcommittee will be taking the
    steps necessary to ensure that our Nation has a sufficient nursing
    workforce to care for the patients of today and tomorrow and that our
    Nation continues to make gains in our fight against cancer.
                                     ______

    Prepared Statement of the Population Association of America/Association
                             of Population Centers
    Introduction
        Thank you, Mr. Chairman Harkin, Mr. Ranking Member Cochran, and
    other distinguished members of the subcommittee, for this opportunity
    to express support for the National Institutes of Health (NIH), the
    National Center for Health Statistics (NCHS), and Bureau of Labor
    Statistics (BLS).
    Background on the Population Association of America (PAA)/Association
            of Population Centers (APC) and Demographic Research
        The Population Association of America (PAA) is a scientific
    organization comprised of more than 3,000 population research
    professionals, including demographers, sociologists, statisticians, and
    economists. The Association of Population Centers (APC) is a similar
    organization comprised of 40 universities and research groups that
    foster collaborative demographic research and data sharing, translate
    basic population research for policy makers, and provide educational
    and training opportunities in population studies. Population research
    centers are located at public and private research institutions,
    including, for example, the University of Wisconsin--Madison, RAND
    Corporation, State University New York Albany, Brown University, Ohio
    State University, University of North Carolina--Chapel Hill, and
    Pennsylvania State University.
        Demography is the study of populations and how or why they change.
    Demographers, as well as other population researchers, collect and
    analyze data on trends in births, deaths, and disabilities as well as
    racial, ethnic, and socioeconomic changes in populations. Major policy
    issues population researchers are studying include the demographic
    causes and consequences of population aging, trends in fertility,
    marriage, and divorce and their effects on the health and well being of
    children, and immigration and migration and how changes in these
    patterns affect the ethnic and cultural diversity of our population and
    the Nation's health and environment.
        The NIH mission is to support research that will improve the health
    of our population. The health of our population is fundamentally
    intertwined with the demography of our population. Recognizing the
    connection between health and demography, the NIH supports extramural
    population research programs primarily through the National Institute
    on Aging (NIA) and the Eunice Kennedy Shriver National Institute of
    Child Health and Human Development (NICHD).
    NIA
        According to the Census Bureau, by 2029, all of the baby boomers
    (those born between 1946 and 1964) will be age 65 years and older. As a
    result, the population age 65-74 years will increase from 6 percent to
    10 percent of the total population between 2005 and 2030. This
    substantial growth in the older population is driving policymakers to
    consider dramatic changes in Federal entitlement programs, such as
    Medicare and Social Security, and other budgetary changes that could
    affect programs serving the elderly. To inform this debate,
    policymakers need objective, reliable data about the antecedents and
    impact of changing social, demographic, economic, and health
    characteristics of the older population. The NIA Division of Behavioral
    and Social Research (BSR) is the primary source of Federal support for
    research on these topics.
        In addition to supporting an impressive research portfolio, that
    includes the prestigious Centers of Demography of Aging and Roybal
    Centers for Applied Gerontology Programs, the NIA BSR program also
    supports several large, accessible data surveys. One of these surveys,
    the Health and Retirement Study (HRS), has become one of the seminal
    sources of information to assess the health and socioeconomic status of
    older people in the United States. Since 1992, the HRS has tracked
    27,000 people, providing data on a number of issues, including the role
    families play in the provision of resources to needy elderly and the
    economic and health consequences of a spouse's death. HRS is
    particularly valuable because its longitudinal design allows
    researchers: (1) the ability to immediately study the impact of
    important policy changes such as Medicare Part D; and (2) the
    opportunity to gain insight into future health-related policy issues
    that may be on the horizon, such as HRS data indicating an increase in
    pre-retirees self-reported rates of disability. In 2009 and 2010, HRS
    is seeking to increase its minority sample size and collect unique,
    enhanced data on the effects of the current economic downturn on older
    people.
        With additional support in fiscal year 2010, the NIA BSR program
    could fully fund its existing centers programs and support its ongoing
    surveys without resorting to cost cutting measures, such as cutting
    sample size. Currently, the Demography of Aging and Roybal Centers
    programs are recompeting their 5-year awards. Additional funding may
    give the Institute resources it needs to award more center grants. NIA
    could also use additional resources to improve its funding payline and
    sustain training and research opportunities for new investigators.
    NICHD
        Since its establishment in 1968, the NICHD Center for Population
    Research has supported research on population processes and change.
    Today, this research is housed in the Center's Demographic and
    Behavioral Sciences Branch (DBSB). The Branch encompasses research in
    four broad areas: family and fertility, mortality and health, migration
    and population distribution, and population composition. In addition to
    funding research projects in these areas, DBSB also supports a highly
    regarded population research infrastructure program and a number of
    large database studies, including the Fragile Families and Child Well
    Being Study, New Immigrant Study, and National Longitudinal Study of
    Adolescent Health.
        NIH-funded demographic research has consistently provided critical
    scientific knowledge on issues of greatest consequence for American
    families: work-family conflicts, marriage and childbearing, childcare,
    and family and household behavior. However, in the realm of public
    health, demographic research is having an even larger impact,
    particularly on issues regarding adolescent and minority health.
    Understanding the role of marriage and stable families in the health
    and development of children is another major focus of the NICHD DBSB.
    Consistently, research has shown children raised in stable family
    environments have positive health and development outcomes.
    Policymakers and community programs can use these findings to support
    unstable families and improve the health and well-being of children.
        One of the most important programs the NICHD DBSB supports is the
    Population Research Infrastructure Program (PRIP). Through PRIP,
    research is conducted at private and public research institutions
    nationwide. The primary goal of PRIP is ``to facilitate
    interdisciplinary collaboration and innovation in population research,
    while providing essential and cost-effective resources in support of
    the development, conduct, and translation of population research.''
    Population research centers supported by PRIP are focal points for the
    demographic research field where innovative research and training
    activities occur and resources, including large-scale databases, are
    developed and maintained for widespread use.
        With additional support in fiscal year 2010, NICHD could restore
    full funding to its large-scale surveys, which serve as a resource for
    researchers nationwide. Furthermore, the Institute could apply
    additional resources toward improving its funding payline, which has
    been as low as the 10th percentile prior to the recent infusion of ARRA
    funds. Additional support could be used to support and stabilize
    essential training and career development programs necessary to prepare
    the next generation of researchers and to support and expand proven
    programs, such as PRIP.
    NCHS
        Located within the Centers for Disease Control (CDC), NCHS is the
    Nation's principal health statistics agency, providing data on the
    health of the U.S. population and backing essential data collection
    activities. Most notably, NCHS funds and manages the National Vital
    Statistics System, which contracts with the States to collect birth and
    death certificate information. NCHS also funds a number of complex
    large surveys to help policy makers, public health officials, and
    researchers understand the population's health, influences on health,
    and health outcomes. These surveys include the National Health and
    Nutrition Examination Survey (NHANES), National Health Interview Survey
    (HIS), and National Survey of Family Growth. Together, NCHS programs
    provide credible data necessary to answer basic questions about the
    state of our Nation's health.
        Despite a funding increase last year, NCHS continues to feel the
    effects of long-term funding shortfalls, compelling the agency to
    undermine, eliminate, or further postpone the collection of vital
    health data. For example, in 2009, sample sizes in HIS and NHANES have
    been cut, while other surveys, most notably the National Hospital
    Discharge Survey, are not being fielded. In addition, in 2009, NCHS has
    proposed purchasing only ``core items'' of vital birth and death
    statistics from the States (starting in 2010), effectively eliminating
    three-fourths of data routinely used to monitor maternal and infant
    health and contributing causes of death.
        The administration recommends NCHS receive $138 million in fiscal
    year 2010. PAA and APC, as members of The Friends of NCHS, support the
    administration's request, but also hope Congress will give the agency
    an additional $15 million in fiscal year 2010. The additional $15
    million should be designated specifically for supporting the States so
    they can modernize their vital statistics systems and make all
    collections electronic according to the 2003 birth and death
    certificates. If NCHS receives this funding, they can abandon their
    proposal to collect core vs. enhanced vital statistics data as well and
    focus on improving the current system. The underlying fiscal year 2010
    budget request should be targeted at precluding further cuts in key
    surveys and collecting the full panel of vital statistics data.
        If Congress fails to, at a minimum, provide the administration's
    fiscal year 2010 request, NCHS will be forced to eliminate over-
    sampling of minority populations in NHANES, which will compromise our
    understanding of health disparities at a time when our society is
    becoming increasingly diverse. Further, we will lose insurance coverage
    information on who's covered and who's not (particularly within
    minority populations), how people are covered and why they're not--at a
    time when Congress and the administration are debating healthcare
    reform. Finally, we will lose vital statistics, adversely affecting the
    amount of data researchers and health practitioners alike need to be
    effective in identifying trends and developing interventions.
    BLS
        During these turbulent economic times, data produced by BLS are
    particularly relevant and valued. PAA and APC members have relied
    historically on objective, accurate data from the BLS. In recent years,
    our organizations have become increasingly concerned about the state of
    the agency's funding.
        We are pleased the administration has requested BLS receive a total
    of $611,623,000 in fiscal year 2010, an increase of $14,441,000 more
    than the 2009 enacted level. According to the agency, this funding
    level would enable BLS to meet its highest-priority goals and
    objectives in 2010. Ideally, the agency will receive enough funding not
    only in 2010, but also in future years to invest in research and assure
    continuous improvement of its measures, including the Consumer Price
    Index. We also hope BLS receives sufficient funds to maintain, or
    increase, the sample sizes of key surveys, such as the Current
    Population Survey. It is imperative sample sizes be increased to ensure
    surveys are accurate and providing adequate detail. We also hope fiscal
    year 2010 marks the beginning of a steady, predicable growth trend in
    the BLS budget.
    Summary of Fiscal Year 2010 Recommendations
        Despite the generous, short-term funding the NIH received from the
    American Recovery and Reinvestment Act (ARRA), the agency faces
    ``falling off the cliff'' in 2011 when ARRA funds expire. Thus, PAA and
    APC, as members of the Ad Hoc Group for Medical Research Funding, are
    asking Congress to provide NIH with and appropriation of $32.4 billion
    in fiscal year 2010, an increase of 7 percent more than the fiscal year
    2009 appropriation. This funding level would put NIH on a stable
    course, ensuring the agency receives an inflationary increase plus
    enough money to support the best research projects, including new and
    innovative projects, and stabilize research training programs in fiscal
    year 2010.
        As part of the NIH request, we also urge the subcommittee to
    appropriate $194.4 million for the National Children's Study (NCS) in
    fiscal year 2010 through the NIH Office of the Director, as proposed by
    the President's budget. This funding will allow for the completion of
    the pilot phase of the NCS.
        PAA and APC, as members of the Friends of NCHS, ask that NCHS
    receive $138 million in fiscal year 2010, with an additional $15
    million set aside for vital statistics infrastructure development. This
    funding is needed to maintain and improve the Nation's vital statistics
    system and to sustain and update the agency's major health survey
    operations.
        Finally, we ask you to support the administration's request, $611.6
    million, for the BLS, in fiscal year 2010.
        Thank you for considering our requests and for supporting Federal
    programs that benefit the field of demographic research.
                                     ______

     Prepared Statement of the Program for Appropriate Technology in Health
                                    overview
        Program for Appropriate Technology in Health (PATH) appreciates the
    opportunity to submit written testimony to the Senate Labor, Health and
    Human Services, Education, and Related Agencies Appropriations
    Subcommittee. PATH is a U.S.-based, international nonprofit
    organization that creates sustainable, culturally relevant solutions
    that enable communities worldwide to break longstanding cycles of poor
    health. By collaborating with diverse public- and private-sector
    partners, we help provide appropriate health technologies and vital
    strategies that change the way people think and act. Our work improves
    global health and well-being.
        The broad, ongoing, and successful struggle to improve global
    health relies on the availability of health interventions and
    technologies designed to prevent, diagnose, and treat disease. Although
    some effective interventions already exist, many more will be necessary
    if existing gains against infectious disease and other global health
    burdens are to be maintained and expanded. The drugs currently
    available for use against diseases that disproportionately impact the
    developing world are often too expensive for use in the developing
    world, and are also subject to disease resistance. Vaccines for many of
    these infectious diseases do not yet exist and diagnostic equipment,
    vaccine delivery devices, microbicides, contraceptives, and other
    health technologies appropriate for the developing world are in many
    cases not available or affordable. Achieving sustainable progress in
    the struggle to improve global health will require developing new
    health technologies, and creating or strengthening infrastructures that
    facilitate their availability to those who need them most.
        Several programs funded in the Labor, Health and Human Services,
    and Education appropriations bill make a particularly critical
    contribution to point-of-care diagnostics, a research area that is key
    to improving health in the developing world. In low-resource settings,
    where many diagnostic tests are difficult to perform and laboratories
    are often inaccessible, there is a great opportunity to make
    significant improvements to global health through the development and
    use of appropriate point-of-care diagnostics. In poor countries,
    healthcare facilities can be far away, serving widely dispersed
    populations. Specialized equipment, personnel, and safe waste disposal
    systems are often not available. Without diagnostic testing, healthcare
    professionals have to rely on just evaluating symptoms to diagnose and
    treat illness--an imperfect method given the similarity of symptoms
    between many diseases. This lack of clarity puts individuals,
    communities, and the world in danger. Incorrect diagnoses can harm
    people and even cost lives. And from a global perspective,
    ineffectively treated disease can become a starting point for epidemic
    or pandemic outbreaks.
        Fortunately, there is an array of promising new tests in the
    pipeline--inexpensive, portable, easy-to-use diagnostics that are
    practical at even small, local health centers, and which can deliver
    results the same day. Some are new takes on established technologies
    like the home pregnancy test. Others are exciting scientific advances.
    Effective diagnosis at, or near, the point of care enables better
    application of available treatment, avoids overuse of antibiotics that
    can promote resistant strains of pathogens, and allows healthcare
    workers to track outbreaks and mobilize resources quickly.
        The National Institutes of Health (NIH) and the Centers for Disease
    Control and Prevention (CDC) continue to make significant contributions
    to the development of new health technologies. Generally speaking, NIH
    carries out the critical basic and preclinical research that provides
    the foundation for new product discovery and development, supports and
    conducts clinical trials of promising products, and develops the in-
    country research capacity of developing world partners. CDC monitors
    and tracks infectious diseases worldwide, provides those involved in
    the control and prevention of these diseases with the critical
    intelligence they need to implement their programs effectively,
    supports researchers in their work by helping to direct their efforts
    towards the areas with the greatest potential for benefit, and warns
    researchers when new trends or disease strains emerge.
        Point-of-care diagnostics are one of the most critical global
    health technologies whose development of testing is supported by NIH
    and CDC. One example of this support is the ongoing and successful
    partnership between the NIH's National Institute of Biomedical Imaging
    and Bioengineering (NIBIB) and PATH. Working together with an
    investment from NIH/NIBIB, PATH formed the Center for Point-of-Care
    Diagnostics for Global Health (GHDx Center), a diagnostics research,
    development, testing, needs assessment and training program that works
    to improve the availability, accessibility, and affordability of
    essential point-of-care diagnostic tests for use in low-resource
    settings around the world. The GHDx Center, managed by PATH in
    collaboration with its partners at the University of Washington, is on
    the cutting edge of developing new diagnostic tools that can be used in
    developing countries to quickly and accurately diagnose diseases that
    disproportionately impact the developing world, but which until now
    have been difficult to accurately diagnose without laboratory
    facilities or extensively trained medical workers.
        The GHDx Center focuses its work on four main areas that encompass
    the breadth of the health technology product development cycle. The
    GHDx Center performs and supports clinical needs assessments that help
    diagnostics developers target the most pressing global health
    challenges and increase the likelihood of product success. It supports
    exploratory technology projects that could have a significant positive
    impact on public health outcomes. It conducts laboratory and field-
    based clinical testing of prototype point-of-care diagnostics. Finally,
    the GHDx Center--in a program led by the University of Washington
    Department of Global Health and Department of Medicine (Division of
    Infectious Diseases)--trains individuals with varied experience and
    backgrounds from the fields of assay and device development, clinical
    laboratories, and disease specialties, with the objective of creating a
    networked group of researchers trained in state-of-the-art technology
    that address the challenges for global health in low-resource settings.
        This extraordinarily promising new program would not have been
    possible without NIH support, and PATH thanks the subcommittee for its
    wise investments in NIH. Without robust funding for NIH and CDC, much
    of the cutting-edge research and development being performed on point-
    of-care diagnostics for the developing world would not be taking place.
    While many commercial and nonprofit groups are working on diagnostic
    technologies, they are not necessarily doing so with an eye toward the
    developing world. For example, their efforts often target diseases that
    mainly concern wealthier countries, or they assume that sophisticated
    laboratories and trained personnel will be available to complement and
    operate their diagnostics. In contrast, diagnostic technologies for
    malaria, enteric diseases, hepatitis b, and other conditions whose
    heaviest burden falls on the developing world, or which can be used in
    resource--poor conditions where laboratory equipment are scarce, do not
    have a significant commercial market that incentivizes research and
    development. Without investment by the U.S. Government, efforts to
    develop these diagnostic technologies--and by doing so improve care and
    reduce the development of drug resistance--would be hindered
    significantly. Expanding funds for these agencies would provide a
    powerful boost to point-of-care diagnostic development and
    availability.
        Another area where agencies funded by this subcommittee are making
    a significant contribution to global health is in the ongoing effort to
    develop and test malaria vaccines. Malaria is a devastating parasitic
    disease transmitted through the bite of infected Anopheles mosquitoes.
    More than one-third of the world's population is at risk of malaria,
    with approximately 250 million cases and 1 million deaths per year, the
    vast majority of which occur among African children under the age of 5.
    A malaria vaccine is desperately needed to confront this deadly disease
    and its impact in the developing world. While consistent use of
    effective insecticides, insecticide-treated nets, and malaria medicines
    saves lives, eradicating or even significantly reducing the impact of
    malaria will require additional interventions, including vaccines.
    Immunization is one of the most effective health interventions
    available. Just as it was necessary to use vaccines to control polio
    and measles in the United States, vaccines are needed as part of an
    effective control strategy for malaria.
        Several Federal agencies are involved in the research and
    development of malaria interventions such as vaccines, as is the PATH
    Malaria Vaccine Initiative (MVI). Indeed, many promising vaccine
    concepts would never have emerged from the laboratory without the
    research performed by Government scientists. Government-sponsored
    research is also critical to eliminating from consideration less
    promising approaches. Unfortunately, funding for this critical research
    at NIH and CDC has been relatively flat for several years. By
    increasing investments in NIH and CDC, Congress can help advance the
    day when a highly effective malaria vaccine is available, thereby
    saving many lives.
        Continued progress in our Nation's effort to improve global health
    requires the development of new tools and technologies. Point-of-care
    diagnostics and, eventually, malaria vaccines, are important components
    of the portfolio of needed tools and technologies, and the development
    of those tools and technologies is heavily reliant on Federal support.
    For this reason, we respectfully request that the subcommittee expand
    funding for research and development at NIH and CDC. We very much
    appreciate the subcommittee's consideration of our views, and we stand
    ready to work with subcommittee members and staff on these and other
    important tropical disease matters.
                                     ______

                Prepared Statement of Prevent Blindness America
                            funding request overview
        Prevent Blindness America (PBA) appreciates the opportunity to
    submit written testimony for the record regarding fiscal year 2010
    funding for vision-related programs. As the Nation's leading nonprofit,
    voluntary organization dedicated to preventing blindness and preserving
    sight, PBA maintains a long-standing commitment to working with
    policymakers at all levels of government, organizations, and
    individuals in the eye care and vision loss community, and other
    interested stakeholders to develop, advance, and implement policies and
    programs that prevent blindness and preserve sight. PBA respectfully
    requests that the subcommittee provide the following allocations in
    fiscal year 2010 to help promote eye health and prevent eye disease and
    vision loss:
      --$4.5 million for the Vision Health Initiative at the Centers for
            Disease Control and Prevention (CDC);
      --$32.4 billion for the National Institutes of Health (NIH) to
            support biomedical research; and
      --$736 million for the National Eye Institute (NEI).
                           introduction and overview
        Vision-related conditions affect people across the lifespan from
    childhood through elder years. Good vision is an integral component to
    health and well-being, affects virtually all activities of daily
    living, and impacts individuals physically, emotionally, socially, and
    financially. Loss of vision can have a devastating impact on
    individuals and their families. An estimated 80 million Americans have
    a potentially blinding eye disease, 3 million have low vision, more
    than 1 million are legally blind, and 200,000 are more severely
    visually blind. Vision impairment in children is a common condition
    that affects 5 to 10 percent of preschool age children. Vision
    disorders (including amblyopia (``lazy eye''), strabismus (``cross
    eye''), and refractive error are the leading cause of impaired health
    in childhood.
        Of serious concern is that the NEI reports ``the number of
    Americans with age-related eye disease and the vision impairment that
    results is expected to double within the next three decades.'' \1\
    Among Americans age 40 and older, the four most common eye diseases
    causing vision impairment and blindness are age-related macular
    degeneration (AMD), cataract, diabetic retinopathy, and glaucoma.\2\
    Refractive errors are the most frequent vision problem in the United
    States--an estimated 150 million Americans use corrective eyewear to
    compensate for their refractive error.\3\ Uncorrected or undercorrected
    refractive error can result in significant vision impairment.\4\
    ---------------------------------------------------------------------------
        \1\ ``Vision Problems in the U.S.: Prevalence of Adult Vision
    Impairment and Age-Related Eye Disease in America,'' Prevent Blindness
    America and the National Eye Institute, 2008.
        \2\ Ibid.
        \3\ Ibid.
        \4\ Ibid.
    ---------------------------------------------------------------------------
        While half of all blindness can be prevented through education,
    early detection, and treatment, it is estimated that the number of
    blind and visually impaired people will double by 2030, if nothing is
    done to curb vision problems. To curtail the increasing incidence of
    vision loss in America, PBA advocates sustained and significant Federal
    funding for vision research and application, as well as resources for
    programs that help promote eye health and prevent eye disease, vision
    loss, and blindness. We thank the subcommittee for its consideration of
    our specific fiscal year 2010 funding requests, which are detailed
    below.
      cdc's vision health initiative: helping to save sight and save money
        The financial costs of vision impairment to our country's fiscal
    health are staggering. PBA estimates that the annual costs of adult
    vision problems in the United States are approximately $51.4
    billion.\5\ The annual cost of untreated amblyopia--reduced vision in
    an eye that has not received adequate use during early childhood--is
    approximately $7.4 billion in lost productivity.\6\ NEI estimates that
    in 2003 the total direct and indirect costs of visual disorders and
    disabilities in the United States were approximately $68 billion, and
    with each passing year these costs continue to escalate.\7\ Vision care
    services consistently have been found to help prevent blindness, reduce
    vision loss, improve quality of life and well-being, increase
    productivity, and reduce costs and burdens on the Nation's healthcare
    system. Therefore, the Nation must increase access to--and awareness of
    the importance of--vision screenings and linkage to appropriate care
    for at-risk and underserved populations, as is provided by the CDC's
    Vision Health Initiative.
    ---------------------------------------------------------------------------
        \5\ ``The Economic Impact of Vision Problems,'' Prevent Blindness
    America, 2007.
        \6\ ``Our Vision for Children's Vision: A National Call to Action
    for the Advancement of Children's Vision and Eye Health, Prevent
    Blindness America,''Prevent Blindness America, 2008.
        \7\ Ellwein Leon. Updating the Hu 1981 Estimates of the Economic
    Costs of Visual Disorders and Disabilities.
    ---------------------------------------------------------------------------
        The CDC reports that ``vision disability is one of the top 10
    disabilities among adults 18 years and older and the single most
    prevalent disabling condition among children.'' \8\ Effective public
    health initiatives can dramatically decrease the number of Americans
    who have vision loss or low vision. Initially funded by Congress in
    fiscal year 2003, the CDC's Vision Health Initiative program has worked
    in a cost-effective way to identify, screen, and link to appropriate
    care individuals at risk for vision loss. This public-private
    partnership combines the resources of the CDC, chronic disease
    directors, State and local Agencies on Aging, and nonprofit
    organizations such as PBA. Highlights of the significant work of the
    CDC's Vision Health Initiative include:
    ---------------------------------------------------------------------------
        \8\ ``Improving the Nation's Vision Health: A Coordinated Public
    Health Approach,'' Centers for Disease Control, 2006.
    ---------------------------------------------------------------------------
      --Support for the eye evaluation component of the National Health and
            Nutrition Examination Survey (NHANES) that provides current,
            nationally representative data and help assess progress for
            vision objectives contained within Healthy People 2010 and the
            future efforts for Healthy People 2020.
      --Development of the first optional Behavioral Risk Factor
            Surveillance System (BRFSS) vision module and introducing it
            into State use in 2005 to gather information about access to
            eye care and prevalence of eye disease and eye injury. Five
            States implemented the module in 2005, and 11 States began
            using the module in 2006.
      --Utilization of applied public health research to address the
            economic costs of vision disorders and develop cost-
            effectiveness models for eye diseases among various
            populations. Estimating the true economic burden is essential
            for informing policymakers and for obtaining necessary
            resources to develop and implement effective interventions.
      --Providing data analyses and a systematic review of interventions to
            promote screening for diabetic retinopathy and reviewing access
            to and utilization of vision care in the United States.
      --Developing best practices for the integration of vision care
            services with community health centers, as well as methods for
            linking clients to appropriate and needed care.
      --Aiding in the translation of science into programs, services, and
            policies and in coordinating service activities with partners
            in the public, private, and voluntary sectors.
        In fiscal year 2009, PBA requested $4.5 million to sustain and
    expand the Vision Health Initiative. In the final fiscal year 2009
    Omnibus Appropriations Act, Congress allocated $3.222 million. PBA
    understands the budgetary challenges facing Congress and the Nation
    and, as such, appreciates this much-needed funding. However, with the
    demographics of eye disease, we strongly feel that a greater investment
    in the Vision Health Initiative must be made, so we can mount an
    adequate effort to address the growing public health threat of
    preventable vision loss among older Americans, low-income, and
    underserved populations.
        To that end, PBA again respectfully requests the subcommittee
    provide a $4.5 million allocation for the Vision Health Initiative.
    Increased fiscal year 2010 funding for this important program will
    support additional vision screenings, increased public awareness
    efforts regarding risk of vision loss, develop best practices for
    linkage to care, and the expansion of eye disease surveillance and
    evaluation systems, which will help ensure our Nation has much-needed
    epidemiological data regarding overall burden and high-risk
    populations, so we can best formulate and assess strategies to prevent
    and reduce the economic and social costs associated with vision loss
    and eye diseases.
                advance and expand vision research opportunities
        Our Nation has benefited from past Federal investment in biomedical
    research at the NIH. Unfortunately, due to flat funding over the past
    six appropriations cycles, NIH has lost 14 percent of its purchasing
    power. While we commend Congress for the $10.4 billion in funding
    provided in the American Recovery and Reinvestment Act, PBA joins the
    broader vision community in advocating a 7 percent increase ($32.4
    billion) for NIH in fiscal year 2010. This level of investment will
    allow NIH to sustain and expand its research progress and avoid the
    potential disruption of vital research that could result from a minimal
    increase.
        PBA also calls upon the subcommittee to provide a specific
    allocation of $736 million for the NEI to bolster its efforts to
    identify the underlying causes of eye disease and vision loss, improve
    early detection and diagnosis of eye disease and vision loss, and
    advance prevention and treatment efforts. Celebrating 40 years of
    service this year, NEI is a leading Institute in translating basic
    research into clinical practice. Just as NIH has seen a decline in
    purchasing power, so too has the NEI, an overall decrease of 18 percent
    in the last 6 appropriations cycles. In fiscal year 2009, NEI's funding
    level of $688 million reflected just 1 percent of the estimated $68
    billion annual costs of eye disease and vision impairment. Despite
    significant funding challenges, NEI has maintained its impressive
    record of breakthroughs in basic and clinical research that have
    resulted in treatments and therapies to save and restore vision and
    prevent eye disease. However, NEI will be challenged further, as 2010
    begins the decade in which more than half of the 78 million Baby
    Boomers will turn 65 and be at greatest risk for developing aging eye
    disease. Adequate funding to NEI is a cost-effective investment in our
    Nation's health, as it can delay, save, and prevent eye disease-related
    expenditures, especially to the Medicare and Medicaid programs.
        investing in the vision of our nation's most valuable resource--
                                    children
        While the risk of eye disease increases after the age of 40, eye
    and vision problems in children are of equal concern, due to the fact
    that, if left untreated, they can lead to permanent and irreversible
    visual loss and/or cause problems socially, academically, and
    developmentally. Although more than 12.1 million school-age children
    have some form of a vision problem, only one-third of all children
    receive eye care services before the age of 6.\9\ Approximately 80
    percent of what a child learns is done so visually.\10\ As such, good
    vision is essential for educational progress, proper physical
    development and athletic performance, and healthy self-esteem in
    growing children. Yet, according to a CDC report, only 1 in 3 children
    in America has received eye care services before the age of 6.
    ---------------------------------------------------------------------------
        \9\ ``Our Vision for Children's Vision: A National Call to Action
    for the Advancement of Children's Vision and Eye Health, Prevent
    Blindness America,'' Prevent Blindness America, 2008.
        \10\ Ottar WL, Scott WK, Holgado SI. Photoscreening for amblyogenic
    factors. J Pediatr Ophthalmol Strabismus. 1995; 32:289-295.
    ---------------------------------------------------------------------------
        Vision screening is an appropriate and essential element of a
    strong public health approach to children's vision care; the sooner
    vision problems are identified, the faster they can be addressed. As
    you know, the Maternal and Child Health Bureau (MCHB) oversees the
    Maternal and Child Health Services State title V (Title V) Block Grant
    program. As a condition of funding under title V, States are required
    to report on certain measures to the MCHB. PBA urges the subcommittee
    to support the development and implementation of a nationwide title V
    core performance measure related to vision screening. A core
    performance measure regarding vision screening will help ensure that
    more children receive comprehensive eye examinations at a young age and
    provide specific information to MCHB and other public health officials
    regarding the progress of the programs and identify areas where
    improvement can be made to provide better vision care to children
    served by the title V program. Specifically, we hope the subcommittee
    will include language in the report accompanying the fiscal year 2010
    Labor, Health and Human Services, and Education, an Related Agencies
    appropriations measure that expresses support for MCHB's work in this
    area.
        We are pleased that the Head Start program currently requires
    children to be screened for vision problems. Unfortunately, there are
    no procedures for training, tracking, or even conducting the screening.
    As such, without a national uniform standard, many Head Start enrollees
    are falling through the cracks and vision problems are not being
    identified in this already often underserved and at-risk population.
    PBA stands ready to work with Head Start, the Congress, and other
    stakeholders to ensure that all Head Start enrollees receive vision
    screening services and other related resources available to them in
    their community. PBA respectfully requests that the subcommittee
    include language in the report accompanying the fiscal year 2010 Labor,
    Health and Human Services, and Education, an Related Agencies
    appropriations measure that encourages collaborations and initiatives
    within the Head Start program to ensure that such screenings are
    delivered and provided in a manner that promotes consistency and
    quality in protocol and administration.
                                   conclusion
        On behalf of PBA, our board of directors, and the millions of
    people at risk for vision loss and eye disease, we thank you for the
    opportunity to submit written testimony regarding fiscal year 2010
    funding for the CDC's Vision Health Initiative, NIH, and NEI. Please
    know that PBA stands ready to work with the subcommittee and other
    Members of Congress to advance policies that will prevent blindness and
    preserve sight.
                                     ______

           Prepared Statement of the Pancreatic Cancer Action Network
        Mr. Chairman and members of the subcommittee: You may recall that
    last year you received testimony from Dr. Randy Pausch, a computer
    science professor at Carnegie Mellon University, author of the widely
    acclaimed ``Last Lecture'', which was released on YouTube and later as
    a book, and at that time, a pancreatic cancer survivor.
        Last year, Randy in his frank and humorous manner, told you that it
    was unlikely that he would survive until Father's Day and that his
    widow, Jai, and three beautiful children, Dillon, Logan, and Chloe
    would have to mark that holiday without him.
        Approximately 76 percent of pancreatic cancer patients die within
    the first year of diagnosis. Randy used to call himself a ``Pancreatic
    Cancer Rock Star'' given that he had already survived 18 months when he
    provided his testimony to you. While I am very happy to report that
    Randy did indeed survive long enough to spend Father's Day with his
    family, he unfortunately passed soon after on July 25, 2008. With his
    passing, we lost a dear friend to the pancreatic cancer community, and
    as I'm sure you would all attest to, a phenomenal pancreatic cancer
    advocate.
        Much has changed in the last year, including some of the
    statistics. According to the American Cancer Society's recently
    released Cancer Facts & Figures 2009, the projected incidence for
    pancreatic cancer rose 12 percent in the last year. Pancreatic cancer
    is now the 10th most commonly diagnosed cancer in both men and women.
        Unfortunately, the survival rate has not changed. Pancreatic cancer
    is still one of the most deadly cancers and is still the fourth-leading
    cause of cancer-related death. It is still true that 95 percent of all
    pancreatic cancer patients die within 5 years of diagnosis, a fact that
    has changed little in the last 30 years. The new statistics show that
    75 percent of these patients die within the first year of diagnosis.
    There are still no early detection or treatment tools for this disease.
    And while pancreatic cancer funding did increase last year, it is also
    still true that pancreatic cancer research is not funded at a level
    that will likely change this picture any time soon.
        The news gets worse as we look to the future. According to an
    article recently released in the Journal of Clinical Oncology,\1\ a 55
    percent increase in pancreatic cancer incidence is expected by 2030.
    This would be among the top five most significant increases across all
    forms of cancer. According to the authors, ``Alarmingly, certain cancer
    sites with particularly high mortality rates, such as liver, stomach,
    pancreas, and lung, will be among those with the greatest relative
    increase in incidence. Therefore, unless substantial improvements in
    cancer therapy and/or prevention strategies emerge, the number of
    cancer deaths may also grow dramatically over the next 20 years.'' We
    simply cannot afford to keep the status quo in terms of funding levels
    or scientific approaches for pancreatic cancer in the face of these
    statistics. We must make finding early detection tools and effective
    treatments for pancreatic cancer and the other highest mortality
    cancers an immediate priority.
    ---------------------------------------------------------------------------
        \1\ Benjamin D. Smith, Grace L. Smith, Arti Hurria, Gabriel N.
    Hortobagyi, and Thomas A. Buchholz, ``Future of Cancer Incidence in the
    United States: Burdens Upon an Aging, Changing Nation,'' Journal of
    Clinical Oncology 27 (April 2009), 4.
    ---------------------------------------------------------------------------
        Admittedly, part of the problem has been the recent flat or
    declining biomedical research budgets. Adjusting for inflation, the
    National Cancer Institute's (NCI) budget has decreased by nearly $639
    million (13.9 percent) since fiscal year 2003. However, it is also
    clear that NCI is not making pancreatic cancer a research priority. In
    fact, the NCI currently allocates just $87 million for pancreatic
    cancer research, a mere 2 percent of its total budget. A percentage
    that is also unchanged from last year.
        We, like many in the cancer and biomedical research communities,
    worked hard to secure funding increases for the National Institute of
    Health (NIH) in the fiscal year 2009 Omnibus Appropriations bill and in
    the American Recovery and Reinvestment Act and we are grateful to you
    for granting the community's requests and providing increases through
    these bills. The Pancreatic Cancer Action Network took part in these
    efforts because we believed that increasing funding through these bills
    would lead to increased funding for pancreatic cancer research.
    Unfortunately, it does not appear that this hope is turning into a
    reality.
        As the National Institute of Health (NIH) was preparing the
    Challenge Grants, we were excited about the potential that these grants
    might bring to the most deadly diseases such as pancreatic cancer.
    Unfortunately, once we had an opportunity to review the Requests for
    Applications (RFAs), we realized that few if any of the grants were
    actually applicable to pancreatic cancer.
        We have also been looking forward to learning more about how NCI
    plans to use their remaining portion of the stimulus funds. Our hope is
    that Dr. Niederhuber will dedicate some portion of the funds for the
    cancers with the highest mortality, defined as those cancers with 5-
    year survival rates of 50 percent or less. Currently, just 8 cancers
    (ovarian, brain, myeloma, stomach, esophageal, lung, liver, and
    pancreatic) account for 50 percent of all cancer deaths. For some of
    these, such as pancreatic and lung cancer, there has been little
    movement in survival rates in the last 30 years.
        As you may know, NIH Director, Dr. Raynard Kington recently asked
    Dr. Niederhuber and Dr. Steve Katz, Director of National Institute of
    Arthritis and Musculoskeletal and Skin Diseases to co-chair a task
    force to develop an NIH-wide cancer research plan in response to the
    President's call to double cancer research funding in 8 years. Ideally,
    this plan would include some defined focus on steps that should be
    taken to reduce mortality for the deadliest cancers. Unfortunately,
    while we have not yet seen the actual plan, based on the NCI's
    statement about it on April 20, 2009 \2\ and based on conversations we
    have had with Dr. Niederhuber earlier this week, we are concerned that
    again, our hopes may not turn into a reality.
    ---------------------------------------------------------------------------
        \2\ National Cancer Institute, National Cancer Institute's Plan to
    Accelerate Cancer Research Announced, http://www.cancer.gov/newscenter/
    pressreleases/AccelerateResearch (April 22, 2009).
    ---------------------------------------------------------------------------
        The mission of the Pancreatic Cancer Action Network is based on
    hope and on action, so it is in the spirit of both that I am today
    submitting testimony. I am not only asking that you significantly
    increase funding for the NCI, but that you also take steps to ensure
    that NCI places special emphasis on the most deadly cancers, including
    pancreatic cancer.
        While I realize that Congress is reluctant to direct how NCI
    allocates research dollars, I would argue that something is wrong when
    one of the deadliest types of cancer receives so little attention. In
    fact, pancreatic cancer research receives the least amount of NCI
    funding of any of the top cancer killers.
        One of our most significant issues in addition to the overall
    funding level, is that there are relatively few researchers studying
    pancreatic cancer--including both young investigators and more
    experienced investigators. While the NCI's commitment to young
    investigators has increased from 2007 when it awarded zero Career
    Development Awards (K awards) or Research Training Awards (F and T
    awards), it still has a long way to go. For example, last year, NCI
    made nearly 180 awards to young breast cancer researchers and more than
    70 K, T, or F awards to young researchers in fields of each of the
    other top 5 cancer killers (lung, colon, and prostate); only 32 were
    awarded to young pancreatic cancer researchers. We can and must do
    better.
        The story is much the same for experienced investigators. In 2008,
    only 32 pancreatic cancer projects were funded at $500,000 or above,
    and only 11 projects received at least $1 million. In contrast, the
    number of projects funded at $500,000 or above was 109 for lung, 114
    for colon, 237 for breast, and 105 for prostate.
        Further, though the pool of researchers that the NCI has funded to
    conduct pancreatic cancer has expanded, it is still a very small pool,
    especially when compared to the numbers of researchers funded in the
    other leading cancer fields. In fact, by way of comparison, in 2008 the
    NCI funded close to 1,600 different investigators in breast cancer
    research, of whom 231 received multiple awards. As many as 91 of these
    researchers received an aggregate of $1 million in funding for their
    research. By comparison, NCI funded 327 different investigators in
    pancreatic cancer research last year, of whom 41 received multiple
    awards and just 13 received an aggregate of $1 million for their
    research.
        Given that the current 5-year survival rate for breast cancer is
    nearly 90 percent, it is clear that a similar pipeline of committed and
    federally funded scientists is needed in pancreatic cancer to help
    speed advances and medical breakthroughs if we are to hope to finally
    increase survival beyond 5 percent.
        The fact is that the number of new pancreatic cancer cases and
    deaths are increasing--not decreasing. The projected number of new
    pancreatic cancer cases is expected to reach 70,000 by 2040. As stated
    above, while overall cancer death rates have significantly declined,
    the 5-year survival rates for pancreatic cancer have remained largely
    unchanged in the last 30 years. If we do not take steps to address this
    issue now, 95 percent of these patients will continue to hear their
    diagnosis expressed as a death sentence.
        Sadly, it is also a fact that for too long, the broader scientific
    research community has faced the challenge of doing more with less.
    While they have achieved some important successes, the funding crisis
    has fostered an environment of focusing on ``safe bets.'' Compared to
    most other cancers, we know relatively little about pancreatic cancer.
    More research is needed in the basic biology of the disease to
    understand how it starts and why it spreads so rapidly. Therefore,
    pancreatic cancer research does not fall into a ``safe bet'' category.
    It falls into the category of high risk/high reward.
        The time has come to not only fund new progress and give our
    researchers the opportunity to do more with more, but to also find new
    ways to encourage the research community to tackle the hardest and most
    complex problems. As Randy mentioned in his testimony last year, it is
    by solving the hardest problems that we will likely see the greatest
    rewards for the entire field. On behalf of the tens of thousands of
    pancreatic cancer patients who die without a chance, including Dr.
    Randy Pausch, I am asking that you not only inject significant new
    funding into the cancer research community, but that you also issue a
    challenge to the NCI to focus on the hardest problems by placing
    special emphasis on finding answers for the most deadly cancers,
    including pancreatic. Doing so will not only fuel progress, but will
    also generate jobs and stem the current trend of losing American-
    trained researchers to other countries more willing to invest in
    scientific research.
        We therefore join with our partners in the One Voice Against Cancer
    coalition to ask that you provide $5.96 billion in funding for the NCI
    in fiscal year 2010--an increase of $993 million (20 percent) more than
    fiscal year 2009. We recognize that this is a significant request.
    However, the reality is that this is the minimum amount needed to make
    true progress on all forms of cancer, including pancreatic and the
    other cancers for which we have yet to see significant improvement in
    survival.
        We also respectfully request that you work with us to ensure that
    NCI creates a strategic plan for the highest mortality cancers, defined
    as those with 5 survival rates below 50 percent, and that the NIH-wide
    cancer research plan that is currently under development also includes
    these cancers as a specific area of focus.
                                     ______

          Prepared Statement of the Pulmonary Hypertension Association
        Mr. Chairman, thank you for the opportunity to submit testimony on
    behalf of the Pulmonary Hypertension Association (PHA).
        I would like to extend my sincere thanks to the subcommittee for
    your past support of pulmonary hypertension (PH) programs at the
    National Institutes of Health (NIH), Centers for Disease Control and
    Prevention (CDC), and Health Resources and Services Administration
    (HRSA). These initiatives have opened many new avenues of promising
    research, helped educate hundreds of physicians in how to properly
    diagnose PH, and raised awareness about the importance of organ
    donation and transplantation within the PH community.
        In addition, I want to commend the subcommittee for actively
    addressing the current backlog in Social Security Disability
    applications at the Social Security Administration. Many PH patients
    end up applying for disability coverage, and streamlining the benefits
    process would go a long way toward improving the quality of life for
    our most in-need families.
        I am honored today to represent the hundreds of thousands of
    Americans who are fighting a courageous battle against a devastating
    disease. PH is a serious and often fatal condition where the blood
    pressure in the lungs rises to dangerously high levels. In PH patients,
    the walls of the arteries that take blood from the right side of the
    heart to the lungs thicken and constrict. As a result, the right side
    of the heart has to pump harder to move blood into the lungs, causing
    it to enlarge and ultimately fail.
        PH can occur without a known cause or be secondary to other
    conditions such as: collagen vascular diseases (i.e., scleroderma and
    lupus), blood clots, HIV, sickle cell, or liver disease. PH does not
    discriminate based on race, gender, or age. Patients develop symptoms
    that include shortness of breath, fatigue, chest pain, dizziness, and
    fainting. Unfortunately, these symptoms are frequently misdiagnosed,
    leaving patients with the false impression that they have a minor
    pulmonary or cardiovascular condition. By the time many patients
    receive an accurate diagnosis, the disease has progressed to a late
    stage, making it impossible to receive a necessary heart or lung
    transplant.
        PH is chronic and incurable with a poor survival rate. Fortunately,
    new treatments are providing a significantly improved quality of life
    for patients with some managing the disorder for 20 years or longer.
        Nineteen years ago, when three PH patients found each other, with
    the help of the National Organization for Rare Diseases, and founded
    the PHA, there were less than 200 diagnosed cases of this disease. It
    was virtually unknown among the general population and not well known
    in the medical community. They soon realized that this was
    unacceptable, and formally established PHA, which is headquartered in
    Silver Spring, Maryland.
        I am pleased to report that we are making good progress in our
    fight against this deadly disease. Six new therapies for the treatment
    of PH have been approved by the FDA in the past 10 years.
        Today, PHA includes:
      --More than 10,000 patients, family members, and medical
            professionals as members and an additional 34,000 supporters
            and friends.
      --A network of more than 200 patient support groups.
      --An active and growing patient-to-patient telephone helpline.
      --Three research programs that, through partnerships with the
            National Heart, Lung and Blood Institute (NHLBI) and the
            American Thoracic Society, have committed more than $7.5
            million toward PH research as of December 2008.
      --Numerous electronic and print publications, including the first
            medical journal devoted to PH--published quarterly and
            distributed to all cardiologists, pulmonologists, and
            rheumatologists in the United States.
        A Web site dedicated to providing educational and support resources
    to patients, medical professionals, and the public. Thanks to support
    from CDC, PHA's online resources now include the PHA Online University
    which provides PH-specific continuing education opportunities to
    medical professionals.
                                the ph community
        Mr. Chairman, I am privileged to serve as the president of the PHA
    and to interact daily with the patients and family members who are
    seeking to live their lives to the fullest in the face of this deadly,
    incurable disease.
        Carl Hicks is a former Army Ranger and a retired Colonel who lead
    the first battalion into Iraq during the first Iraq war. Every member
    of his family was touched by pulmonary hypertension after the diagnosis
    of his daughter Meghan in 1994. I share their story here, in Carl's own
    words:

        ``We're sorry Colonel Hicks, your daughter Meaghan has contracted
    primary pulmonary hypertension. She likely has less than a year to live
    and there is nothing we can do for her. Those words were spoken in the
    spring of 1994 at Walter Reed Army Medical Center. They marked the
    start down the trail of tears for a young military family that, only
    hours before, had been in Germany. My family's journey down this trail
    hasn't ended yet, even though Meaghan's fight came to an end with her
    death on January 30th, 2009. She was 27.
        Pulmonary hypertension struck our family, as it so often does,
    without warning. One day, we had a beautiful, healthy, energetic 12-
    year old gymnast, the next, a child with a death sentence being robbed
    of every breath by this heinous disease. The toll of this fight was
    far-reaching. Over the years, every decision of any consequence in the
    family was considered first with regards to its impact on Meaghan and
    her struggle for breath.
        The investment made by our country in my career was lost, as I left
    the service to stay nearer my family. The costs for Meaghan's medical
    care, spread over the nearly 14 years of our fight, ran well into the 7
    figures. Meghan even underwent a heart and dual-lung transplant These
    challenges, though, were nothing compared to the psychological toll of
    losing Meaghan who had fought so hard for something we all take for
    granted, a breath of air.''

        Over the past decade, treatment options, and the survival rate, for
    PH patients have improved significantly. As Meaghan's story
    illustrates, however, courageous patients of every age lose their
    battle with PH each day. There is still a long way to go on the road to
    a cure and biomedical research holds the promise of a better tomorrow.
        Thanks to congressional action, and to advances in medical research
    largely supported by the NHLBI and other Government agencies, PH
    patients have an increased chance of living with their PH for many
    years. However, additional support is needed for research and related
    activities to continue to develop treatments that will extend the life
    expectancy of PH patients beyond the NIH estimate of 2.8 years after
    diagnosis.
                fiscal year 2010 appropriations recommendations
    NHLBI
        Recently, the World Health Organization's Fourth World Symposium on
    Pulmonary Hypertension brought together PH experts from around the
    world. According to these leading researchers, we are on the verge of
    significant breakthroughs in our understanding of PH and the
    development of new and advanced treatments. Fifteen years ago, a
    diagnosis of PH was essentially a death sentence, with only one
    approved treatment for the disease. Thanks to advancements made through
    the public and private sector, patients today are living longer and
    better lives with a choice of six FDA approved therapies. Recognizing
    that we have made tremendous progress, we are also mindful that we are
    a long way from where we want to be in (1) the management of PH as a
    treatable chronic disease, and (2) a cure.
        One crucial step in continuing the progress we have made in the
    treatment of PH is the creation of a pulmonary hypertension research
    network. Such a network would link leading researchers around the
    United States, providing them with access to a wider pool of shared
    patient data. In addition, the network would provide researchers with
    the opportunities to collaborate on studies and to strengthen the
    interconnections between basic and clinical science in the field of
    pulmonary hypertension research. Such a network is in the tradition of
    the NHLBI, which, to its credit and to the benefit of the American
    public, has supported numerous similar networks including the Acute
    Respiratory Distress Syndrome Network and the Idiopathic Pulmonary
    Fibrosis Clinical Research Network.
        In order to maintain the important momentum in pulmonary
    hypertension research that has developed over the past few years, and
    to create a much needed pulmonary hypertension research network, the
    Pulmonary Hypertension Association encourages the subcommittee to
    provide the NIH, particularly the NHLBI, with a 7 percent increase in
    funding in fiscal year 2010.
    CDC
        PHA applauds the subcommittee for its leadership over the years in
    encouraging CDC to initiate a Pulmonary Hypertension Education and
    Awareness Program. We know for a fact that Americans are dying due to a
    lack of awareness of PH, and a lack of understanding about the many new
    treatment options. This unfortunate reality is particularly true among
    minority and underserved populations.
        Mr. Chairman, we are grateful to the Congress for providing
    $238,000 in support of a pulmonary hypertension awareness program in
    fiscal year 2009. By educating physicians and patients about pulmonary
    hypertension, this funding will save lives. We encourage the
    subcommittee to continue its support for PH awareness activities
    through the CDC in fiscal year 2010.
    ``Gift of Life'' Donation Initiative at HRSA
        Mr. Chairman, PHA applauds the success of HRSA's ``Gift of Life''
    Donation Initiative. This important program is working to increase
    organ donation rates across the country. Unfortunately, the only
    ``treatment'' option available to many late-stage PH patients is a
    lung, or heart and lung, transplantation. This grim reality is why PHA
    established ``Bonnie's Gift Project.''
        ``Bonnie's Gift'' was started in memory of Bonnie Dukart, one of
    PHA's most active and respected leaders. Bonnie battled with PH for
    almost 20 years until her death in 2001 following a double lung
    transplant. Prior to her death, Bonnie expressed an interest in the
    development of a program within PHA related to transplant information
    and awareness. PHA will use ``Bonnie's Gift'' as a way to disseminate
    information about PH, transplantation, and the importance of organ
    donation, as well as organ donation cards, to our community.
        PHA has had a very successful partnership with HRSA's ``Gift of
    Life'' Donation Program in recent years. Collectively, we have worked
    to increase organ donation rates and raise awareness about the need for
    PH patients to ``early list'' on transplantation waiting lists. For
    fiscal year 2010, PHA recommends an appropriation of $30 million for
    this important program.
                                     ______

     Prepared Statement of the Religious Coalition for Reproductive Choice
        Mr. Chairman and members of the subcommittee: The Religious
    Coalition for Reproductive Choice (RCRC) appreciates this opportunity
    to submit testimony. We strongly support President Obama's proposal to
    eliminate the dedicated funding streams for abstinence-only programs
    and to support proven teen pregnancy prevention programs.
        RCRC is an interfaith alliance of national mainstream religious
    organizations dedicated to ensuring access to reproductive healthcare
    and achieving reproductive justice. For more than 35 years, RCRC has
    brought together 40 national religious and religiously affiliated
    organizations from 15 denominations and traditions. Our membership
    includes the Episcopal Church, the Presbyterian Church (USA), the
    United Church of Christ, the United Methodist Church (General Board of
    Church and Society and Women's Division, General Board of Global
    Ministries), the Unitarian Universalist Association of Congregations;
    and Reform, Reconstructionist and Conservative Judaism.
        As faith communities, we are committed to sex education in our
    public schools that empowers and protects young people, honors diverse
    values, and promotes the highest ethical standards. Religious Americans
    overwhelmingly favor responsible sex education that is complete, age
    appropriate and includes accurate information about abstinence and
    contraception.
        Abstinence-only-until-marriage programs cannot offer this and
    moreover they are ineffective. These programs often are dishonest and
    scientifically inaccurate. There is no justification for endangering
    the health and well-being of the young people of our Nation for the
    sake of a very parochial moral vision.
        In fact, while there certainly is great value in adolescents
    postponing sex until they are mature, Federal policies that withhold
    important life saving information about STDs or HIV/AIDS or other
    aspects of reproductive health raise serious moral and ethical
    questions. Young people have a basic human right to complete and
    accurate HIV/AIDS and sexual health information. Without it they will
    be unable to realize the highest attainable standard of health and for
    some, their futures will be compromised with disease or unintended
    pregnancy.
     support of religious communities for comprehensive sexuality education
        Major faith traditions representing millions of Americans support
    comprehensive sex education. In keeping with our Nation's
    constitutional guarantee of freedom of religion, they oppose civil laws
    that would impose specific religious views about sexuality education on
    all Americans.
        These faith communities take seriously their duty to instill a set
    of religious and moral values that will help guide young people to
    responsible life choices. They believe that it is the role of
    Government to ensure that the Nation's youth receive the facts--
    unblemished by ideology--that will protect them from disease and
    unintended pregnancy.
        RCRC has compiled excerpts of official statements of religious
    denominations and traditions on the importance of sexuality education.
    We have attached a copy of the complete document, Religious Communities
    and Sexuality Education: In the Home, In the Congregation, In the
    Schools, for your review. But to give you a brief taste of these
    statements, please consider the following:
        United Methodist Church
      --``Children, youth and adults need opportunities to discuss
            sexuality and learn from quality sex education materials in
            families, churches and schools.''
        United Synagogue of Conservative Judaism
      --``. . . supports comprehensive sex education . . . calls upon the
            U.S. Congress to cease funding of abstinence only education.''
        Presbyterian Church (U.S.A.)
      --``. . . supports . . . comprehensive school health education that
            includes age and developmentally appropriate sexuality
            education in all grades . . .''
        Muslim Women's League
      --``Sex education can be taught in a way that informs young people
            about sexuality in scientific and moral terms.''
        Episcopal Church
      --``. . . we encourage the members of this Church to give strong
            support to responsible local public and private school programs
            of education in human sexuality.''
                    need for attention to disease prevention
        Although the President's budget does not link the issues of teen
    pregnancy prevention and disease prevention, we know that the most
    effective programs are comprehensive and do connect the two. According
    to the American Social Health Association, each year 9 million new
    cases of STDs occur among young people aged 15-24. Sexually active
    youth have the highest STD rates of any age group in the country. Young
    people are at greatest risk for STDs because, as a group, they are more
    likely to have unprotected sex.
        The health consequences of STDs include chronic pain, infertility,
    cervical cancer and increased vulnerability to HIV, the virus that
    causes AIDS. The transmission of STDs to babies--prenatally, during
    birth or after--can cause serious life-long complications and even
    death.
        We urge the Appropriations Committee to include language that
    expands the requirement for funded programs to include disease
    prevention.
        How did you learn about sex?
        This past year, RCRC put out a request to ``tell us your story: how
    did you learn about sex?'' We received well more than 400 responses
    from individuals around the country age 17 through 94. These replies
    offer thoughtful reflections and often intimate, sometimes painful,
    glimpses into personal lives.
        Among other things, we found that what you learn--or don't learn--
    as a young person can have life-long repercussions. And abstinence-only
    programs, by their design, leave out important health information.

        ``If I had known what sex was, I would have understood what was
    happening to me when I was molested by a male relative beginning at age
    8.''----Deborah, 45
        ``I wish I'd learned what intercourse was and how easy it is to get
    pregnant.''----Anonymous, 79
        ``I wish I'd learned about STDs and the way in which they can be
    transmitted. I was under the impression that oral sex was safe, since
    you couldn't get pregnant from it.''----Miranda, 26
        ``The good girl/bad girl images prevalent when I was young only
    served to instill a great deal of fear in me, which negatively impacted
    on my marriage for years.''----Anonymous, 57
                              communities of color
        According to former Surgeon General Joycelyn Elders, the black
    community's ``problem with sexuality has contributed more to the
    poverty in the black community than anything else in our society. A
    pregnant teenager who does not finish high school or marry has an 80
    percent likelihood of being poor.'' She challenged Congress to ``stop
    legislating morals and start teaching responsibility.'' Abstinence-only
    education has been proved through studies and in harsh reality to be a
    horrible failure. A low-income woman is four times as likely to have an
    unintended pregnancy, five times as likely to have an unintended birth
    and more than four times as likely to have an abortion as her higher-
    income counterpart. It is the poor and communities of color who suffer
    from illogical and ineffective public policy. The denominations and
    people of faith that comprise RCRC agree with Dr. Elders that ``If I
    could make any changes at all to the current health care system, you
    know I would start with education, education, education. You can't
    educate people that are not healthy. But you certainly can't keep them
    healthy if they're not educated.''
        RCRC addresses these issues through our National Black Church
    Initiative, a program begun in 1997 to ``break the silence'' about sex
    and sexuality in the African American community. The initiative assists
    Black clergy and laity in addressing teenage pregnancy, sexuality
    education and reproductive health within the context of African
    American religion and culture. We have worked in more than 700 churches
    providing our ``Keeping It Real!'' faith based sexuality education
    curriculum to more than 7,000 young men and women. We have a similar
    faith based initiative, La Iniciativa Latina (LIL), which provides
    model programs on sexuality and reproductive health for Latino youth,
    adults and clergy in the context of Latino values, religion and
    culture.
        But the answer to the Nation's high rate of unintended pregnancy
    and pandemic of sexually transmitted diseases does not rest with
    churches and nonprofit organizations alone. Public schools must be part
    of the solution. We are morally compelled to empower our young people
    with the knowledge to make responsible decisions. As Dr. Elders so
    succinctly stated, ``Vows of abstinence break more easily than latex
    condoms.'' According to the CDC's National Center for Health
    Statistics, in 2002, the pregnancy rates for black and Hispanic
    teenagers were each more than two and one-half times the rate for white
    teenagers. This is the reality.
        One of the most compelling arguments for comprehensive sexuality
    education was made by a member of our youth program, a proud
    Pentecostal Christian from rural Mississippi. In a meeting with her
    Member of Congress, she explained that there was no sex education in
    her high school and a lot of girls in her class got ``knocked up.''
    They did not graduate from high school. They did not marry. Their
    futures were compromised. But the impact of these unintended
    pregnancies goes well beyond the lives of these young women and their
    children. They contribute to the economic depression of their
    communities.
                                   conclusion
        Let's be real and make a real difference. We know that 95 percent
    of Americans will have sex before they marry; therefore programs need
    to teach about abstinence and also about contraception, relationships
    and disease prevention. We must empower youth with the knowledge to
    make responsible decisions.
        We believe that being of faith means being engaged in the world.
    And like it or not, the facts are clear: more than 80 percent of the
    750,000 teen pregnancies each year are unintended and 25 percent of
    American teens contract an STD. We want our young people to be safe.
    For that to happen, they must be informed by comprehensive sex
    education. Offering them anything less is irresponsible and dangerous.
                                     ______

              Prepared Statement of the Railroad Retirement Board
        Mr. Chairman and members of the committee: We are pleased to
    present the following information to support the Railroad Retirement
    Board's (RRB) fiscal year 2010 budget request.
        The RRB administers comprehensive retirement/survivor and
    unemployment/sickness insurance benefit programs for railroad workers
    and their families under the Railroad Retirement and Railroad
    Unemployment Insurance Acts. The RRB also has administrative
    responsibilities under the Social Security Act for certain benefit
    payments and Medicare coverage for railroad workers. During fiscal year
    2008, the RRB paid $10.1 billion in retirement/survivor benefits and
    vested dual benefits to about 598,000 beneficiaries. We also paid $80
    million in net unemployment/sickness insurance benefits to about 30,000
    claimants.
                   proposed funding for agency administration
        The President's proposed budget would provide $109,073,000 for
    agency operations, which would enable us to maintain a staffing level
    of 920 full-time equivalent staff years in 2010. The proposed budget
    would also provide about $1,651,000 for information technology (IT)
    investments. This includes $615,000 for costs related to information
    security and privacy, and for continuity of operations in the event of
    an emergency. The remaining IT funds will be used for E-Government
    initiatives, systems modernization, infrastructure needs and system
    support.
                                agency staffing
        The RRB's dedicated, experienced employees have been the foundation
    for our tradition of excellence in customer service and satisfaction.
    And, we have an ongoing need and responsibility to effectively manage
    our human capital resources. This is particularly important given the
    number of RRB employees who are eligible for retirement and those who
    soon will be. We are developing a long-range approach to workforce
    planning that will position the agency for continued success in
    administering our programs. This includes a detailed analysis of the
    demographic features of the RRB workforce and the skills needed to
    fulfill our mission. It will also establish a procedural framework for
    recruiting, training, and developing talented employees.
        Like many agencies, the RRB has an aging workforce. About 30
    percent of our workforce is currently eligible to retire, and more than
    50 percent will be eligible by fiscal year 2012. In response to this
    trend, we have placed added emphasis on filling entry-level positions,
    focusing on front-line service employees and claims examiners to the
    extent possible. In anticipation of an increase in the agency attrition
    rate as more employees become eligible to retire, these new employees
    will be key to effectively administering the RRB's programs and
    continuing to provide excellent service over the long term.
                              service improvements
        In fiscal year 2009, we have implemented nationwide, toll-free
    telephone service, which enables us to dynamically route phone calls
    among our offices based on logical business rules and customer needs.
    In addition to providing our customers with faster response times, the
    toll-free service allows agency management to more effectively balance
    and share workloads among offices. We plan to continue expanding the
    functionality and services offered through the toll-free number (1-877-
    772-5772 or 1-877-RRB-5RRB). Enhancements will focus on new self-
    service options available through the toll-free system.
        The RRB's long-term information technology strategy also calls for
    expanded use of the Internet to provide services to our customers. We
    plan to use contractor services to augment agency staff to expand the
    electronic services available to the railroad public via the RRB's
    website. As part of this strategy, we are continuing to work on the
    Employer Reporting System to increase the amount of information related
    to railroad compensation, employment and service that employers can
    transmit to the RRB through the Internet. In fiscal year 2010, we plan
    to expand services to provide additional notifications to rail
    employers and enable employers to correct data through the system.
                             systems modernization
        Over the last few years, we have undertaken a series of strategic
    measures to improve computer processes and better position the RRB for
    the future. First, the agency moved to a relational database
    environment, and then optimized the data that reside in the legacy
    databases. Our next steps involve modernizing the agency's computer
    processes.
        Many of the RRB's existing systems are old, complex, and require a
    large investment in maintenance. As projected staff attrition occurs,
    we will be losing both experienced technical staff and some of the
    business subject-matter experts who now support our legacy systems. The
    modernization process will enable us to maintain the capability of our
    business function in the face of expected staff turnover, and to
    upgrade our systems based on the improvements that we have already
    completed. Through these initiatives, we will eliminate or reduce
    unnecessary or redundant activities, improve the accuracy and security
    of our systems and their transactions, make the systems more user-
    friendly for agency employees and our customers, improve the
    interoperability and flexibility of systems, and improve the RRB's
    ability to collaborate with agency partners. These improvements will
    ultimately decrease the time and cost to develop and operate RRB
    systems and allow an increased focus on new initiatives.
        We plan to begin this process in fiscal year 2009, with selection
    of the agency's first system to modernize and development of a project
    plan. The selected system will serve as a pilot for further
    modernization. In fiscal year 2010, we will use contractor services to
    evaluate the pilot project's business requirements, identify possible
    solutions, analyze them, and recommend one for implementation.
        The President's proposed budget includes $64 million to fund the
    continuing phase-out of vested dual benefits, plus a 2 percent
    contingency reserve, $1,280,000, which ``shall be available
    proportional to the amount by which the product of recipients and the
    average benefit received exceeds the amount available for payment of
    vested dual benefits.''
        In addition to the requests noted above, the President's proposed
    budget includes $150,000 for interest related to uncashed railroad
    retirement checks.
                      financial status of the trust funds
        Railroad Retirement Accounts.--The RRB continues to coordinate its
    activities with the National Railroad Retirement Investment Trust
    (Trust), which was established by the Railroad Retirement and
    Survivors' Improvement Act of 2001 (RRSIA) to manage and invest
    railroad retirement assets. Pursuant to the RRSIA, the RRB has
    transferred a total of $21.276 billion to the Trust. All of these
    transfers were made in fiscal years 2002 through 2004. The Trust has
    invested the transferred funds, and the results of these investments
    are reported to the RRB and posted periodically on the RRB's website.
    The market value of Trust-managed assets on September 30, 2008, was
    approximately $25.3 billion. Trust-managed assets have declined as a
    result of the general economic downturn in 2008 and the early part of
    2009. The Trust reported that Trust-managed assets amounted to $19.1
    billion as of March 31, 2009. The Trust has transferred to the RRB for
    payment of railroad retirement benefits approximately $7.3 billion
    since the inception of the Trust.
        In June 2008, we released the annual report on the railroad
    retirement system required by section 22 of the Railroad Retirement Act
    of 1974, and section 502 of the Railroad Retirement Solvency Act of
    1983. The report, which reflects changes in benefit and financing
    provisions under the RRSIA, addressed the 25-year period 2008-2032 and
    contained generally favorable information concerning railroad
    retirement financing. The report included projections of the status of
    the retirement trust funds under three employment assumptions. These
    indicated that, barring a sudden, unanticipated, large decrease in
    railroad employment or substantial investment losses, the railroad
    retirement system would experience no cash flow problems throughout the
    projection period. Our next report, which will be released in June
    2009, will include updated projections reflecting the economic events
    of the past year.
        Railroad Unemployment Insurance Account.--The equity balance of the
    Railroad Unemployment Insurance Account at the end of fiscal year 2008
    was $99.9 million, a decrease of $0.8 million from the previous year.
    The RRB's latest annual report on the financial status of the railroad
    unemployment insurance system was issued in June 2008. The report
    indicated that even as maximum daily benefit rates rise 47 percent
    (from $59 to $87) from 2007 to 2018, experience-based contribution
    rates maintain solvency. The report did not recommend any financing
    changes. We will update this analysis in our next annual report on the
    system, which will be released in June 2009.
        In conclusion, we want to stress the RRB's continuing commitment to
    improving our operations and providing quality service to our
    beneficiaries. Thank you for your consideration of our budget request.
    We will be happy to provide further information in response to any
    questions you may have.
                                     ______

              Prepared Statement of the Railroad Retirement Board
        Mr. Chairman and members of the subcommittee: My name is Martin J.
    Dickman and I am the Inspector General for the Railroad Retirement
    Board (RRB). I would like to thank you, Mr. Chairman, and the members
    of the subcommittee for your continued support of the Office of
    Inspector General (OIG).
                   budget request and background information
        I wish to describe our fiscal year 2010 appropriations request and
    our planned activities. The OIG respectfully requests funding in the
    amount of $8,186,000 to ensure the continuation of its independent
    oversight of the RRB.
        The RRB's central mission is to pay accurate and timely benefits.
    During fiscal year 2008, the RRB paid approximately $10.1 billion in
    retirement and survivor benefits to 598,000 beneficiaries. The RRB also
    paid $80 million in net unemployment and sickness insurance benefits to
    almost 30,000 claimants during the benefit year ending June 30, 2008.
        The RRB contracts with a separate Medicare Part B carrier, Palmetto
    GBA, to process Railroad Medicare Part B claims. As of September 30,
    2008, there were 469,442 Railroad Medicare Part B beneficiaries and
    during fiscal year 2008 Palmetto GBA paid more than $844 million in
    medical insurance benefits on their behalf.
        During fiscal year 2010, the OIG will focus on areas affecting
    program performance; the efficiency and effectiveness of agency
    operations; and areas of potential fraud, waste, and abuse.
                              office of audit (oa)
        The mission of the OA is to (1) promote economy, efficiency, and
    effectiveness in the administration of RRB programs, and (2) detect and
    prevent fraud and abuse in such programs. To accomplish its mission OA
    conducts financial, performance and compliance audits and evaluations
    of RRB programs. In addition, OA develops the OIG's response to audit-
    related requirements and requests for information.
        During fiscal year 2010, OA will focus on areas affecting program
    performance, the efficiency and effectiveness of agency operations and
    areas of potential fraud, waste, and abuse. OA will continue its
    emphasis on long-term systemic problems and solutions, and will address
    major issues that affect the RRB's service to rail beneficiaries and
    their families. OA has identified four broad areas of potential audit
    coverage:
      --Financial accountability;
      --Railroad Retirement Act & Railroad Unemployment Insurance Act
            Benefit Program Operations;
      --Railroad Medicare program operations; and
      --Security, privacy, and information management.
        During fiscal year 2010, OA must accomplish the following mandated
    activities with its own staff:
      --Audit of the RRB's financial statements pursuant to the
            requirements of the Accountability of Tax Dollars Act of 2002;
            and
      --Evaluation of information security pursuant to the Federal
            Information Security Management Act (FISMA).
        During fiscal year 2010, OA will complete the audit of the RRB's
    fiscal year 2009 financial statements and begin its audit of the
    agency's fiscal year 2010 financial statements. OA contracts with a
    consulting actuary for technical assistance in auditing the RRB's
    ``Statement of Social Insurance'' which became basic financial
    information effective for fiscal year 2006.
        In addition to performing the annual evaluation of information
    security, OA also conducts audits of individual computer application
    systems which are required to support the annual FISMA evaluation. Our
    work in this area is targeted toward the identification and elimination
    of security deficiencies and system vulnerabilities, including controls
    over sensitive personally identifiable information.
        OA undertakes additional projects with the objective of allocating
    available audit resources to areas in which they will have the greatest
    value. In making that determination, OA considers staff availability,
    current trends in management, congressional and Presidential concerns.
                         office of investigations (oi)
        The OI focuses its efforts on identifying, investigating and
    presenting benefit fraud cases for prosecution. OI conducts
    investigations, throughout the United States, relating to the
    fraudulent receipt of RRB disability, unemployment, sickness,
    retirement/survivor, and Railroad Medicare benefits. OI investigates
    railroad employers and unions when there is an indication that they
    have submitted false reports to the RRB. OI also investigates
    allegations regarding agency employee misconduct and threats against
    RRB employees. Investigative efforts can result in criminal
    convictions, administrative sanctions, civil penalties and/or the
    recovery of program benefit funds.
        OI initiates cases based on information from a variety of sources.
    The agency conducts computer matching of employment and earnings
    information reported to State governments with RRB benefits paid.
    Referrals are made to OI if a match is found. OI also receives
    allegations of fraud through the OIG Hotline, contacts with State,
    local and Federal agencies, and information developed through audits
    conducted by the OIG's OA.
        OI's investigative results from October 1, 2008 through March 31,
    2009 are:

    ----------------------------------------------------------------------------------------------------------------
           Civil judgments          Indictments/information           Convictions           Recoveries/collections
    ----------------------------------------------------------------------------------------------------------------
    12..........................                          16                          29                  $5,125,573
    ----------------------------------------------------------------------------------------------------------------

        OI anticipates an ongoing caseload of approximately 450
    investigations in fiscal year 2010. At present, OI has cases open in 47
    States, the District of Columbia, and Canada with estimated fraud
    losses totaling almost $16 million.
        OI will continue to concentrate its resources on cases with the
    highest fraud losses. Typically, these cases are related to the RRB's
    disability program. Disability fraud cases currently constitute
    approximately 50 percent of OI's total caseload. These cases involve
    more complicated schemes and result in the recovery of substantial
    funds for the agency's trust funds. They also require considerable time
    and resources such as travel by special agents to conduct sophisticated
    investigative techniques such as surveillance and witness interviews.
    These fraud investigations are extremely document-intensive and involve
    complicated financial analysis.
        Since March 2008, OI has added Railroad Medicare fraud
    investigations to its caseload and has identified 35 cases which
    involve losses to the Railroad Medicare program. Similar to the
    disability fraud matters, Medicare fraud cases are extremely complex in
    nature and often involve extensive document/data reviews that demand
    significant resources.
        OI will continue to investigate fraud violations of railroad
    employees collecting unemployment or sickness insurance benefits while
    working and receiving wages from an employer. OI will also investigate
    retirement fraud and will continue to use the Department of Justice's
    Affirmative Civil Enforcement Program to recover trust fund monies from
    cases that do not meet U.S. Attorney's guidelines for criminal
    prosecution.
        OI will also investigate complaints involving administrative
    irregularities and any alleged misconduct by agency employees.
        In fiscal year 2010, OI will continue to coordinate its efforts
    with agency program managers to address vulnerabilities in benefit
    programs that allow fraudulent activity to occur and will recommend
    changes to ensure program integrity. OI plans to continue proactive
    projects to identify fraud matters that are not detected through the
    agency's program policing mechanisms.
                   requested change in operational authority
    Oversight of the National Railroad Retirement Investment Trust
        The National Railroad Retirement Investment Trust (NRRIT) was
    established by the Railroad Retirement and Survivors' Improvement Act
    of 2001 (RRSIA) to manage and invest Railroad Retirement assets. As of
    February 28, 2009, the RRB's investments in the NRRIT were valued at
    approximately $18.3 billion. Although the Trust is a tax-exempt entity
    independent of the Federal Government, RRSIA requires the Trust to
    report to the RRB. This office has previously reported its concerns
    about the RRB's passive relationship with the NRRIT and has identified
    the RRB's oversight in this area as a critical issue. However, the
    RRSIA does not provide the OIG with oversight authority to conduct
    audits and investigations of the NRRIT. This office believes that
    independent oversight of the Trust's operations is necessary to ensure
    that sufficient reporting mechanisms are in place and to ensure that
    the Trustees are fulfilling their fiduciary responsibilities. The OIG
    respectfully requests oversight and enforcement authority to conduct
    audits and investigations of the NRRIT.
                                    summary
        In fiscal year 2010, the OIG will continue to focus its resources
    on the review and improvement of RRB operations and will conduct
    activities to ensure the integrity of the agency trust funds. This
    office will continue to work with agency officials to ensure the agency
    is providing quality service to railroad workers and their families.
    The OIG will also aggressively pursue all individuals who engage in
    activities to fraudulently receive RRB funds. The OIG will continue to
    keep the subcommittee and other members of Congress informed of any
    agency operational problems or deficiencies. The OIG sincerely
    appreciates it cooperative relationship with the agency and the ongoing
    assistance extended to its staff during the performance of their audits
    and investigations. Thank you for your consideration.
                                     ______

        Prepared Statement of the Ryan White Medical Providers Coalition
        Dear Chairman and Ranking Member: I am Dr. Kathleen Clanon, an HIV
    physician and director of the Tri-City Health Center's HIVACCESS
    program in Oakland, California. I am submitting public testimony on
    behalf of the Ryan White Medical Providers Coalition (RWMPC). I
    appreciate the opportunity to discuss the important HIV/AIDS care
    conducted at Ryan White Part C funded programs around the country and
    to request a dramatic increase in funds. Specifically, we recommend a
    $68.4 million increase for part C for fiscal year 2010 resulting in a
    total appropriation of $270,254,000.
        Our coalition was formed in 2006 to be a voice for medical
    providers across the Nation delivering quality care to their patients
    through part C of the Ryan White program. We represent every kind of
    program from small and rural to large urban sites in every region in
    the country. Our membership has rapidly increased as word spread that
    an advocacy group was forming to speak on behalf of the needs of part C
    programs.
        Ryan White Part C funds comprehensive HIV care and treatment--the
    services that are directly responsible for the dramatic decreases in
    AIDS-related mortality and morbidity over the last decade. We speak for
    those who often cannot speak for themselves and we advocate for a full
    range of primary care services for this unique population. Sufficient
    funding for part C is essential for the work that we do in service of
    those living with HIV/AIDS.
        While the patient load in our programs is rising in number, funding
    for part C has effectively decreased. At the same time, we expect a
    continued increase in patients due to higher diagnosis rates and
    declining insurance coverage. The Centers for Disease Control and
    Prevention (CDC) reports that the number of HIV/AIDS cases increased by
    15 percent from 2004 to 2007 in 34 States.\1\ Our patients struggle in
    times of plenty; during this economic downturn they will rely on our
    comprehensive services more than ever. An increase in funding is
    critical to ensure that we are able to sustain and improve our current
    staffing levels, which is important to ensure access to healthcare for
    our patients, as well as, to provide security to our community. Part C
    of the Ryan White program has been under-funded for years, but new
    pressures are creating a crisis in our community. The HIV medical
    clinics funded through part C have been in dire of increased funding
    for years. An infusion of new funding would offer much needed
    assistance. Years of near flat funding, combined with large increases
    in the patient population, are negatively impacting the ability of part
    C providers to serve their patients.
    ---------------------------------------------------------------------------
        \1\ Centers for Disease Control and Prevention. HIV/AIDS
    Surveillance Report, 2007. Vol. 19. U.S. Department of Health and Human
    Services, Centers for Disease Control and Prevention; 2009:5
    www.cdc.gov/hiv/topics/surveillance/resources/reports.
    ---------------------------------------------------------------------------
        With the rapid cost increases in all aspects of healthcare
    delivery, despite small funding increases programs are still operating
    at a funding deficit because we are serving more patients than ever. In
    2008, part C programs will treat an estimated 248,070--a dramatic 30
    percent increase in less than 10 years. Our clinics are laying off
    staff, discontinuing critical services such as laboratory monitoring,
    creating waitlists, and operating on a 4-day work week just to get by.
    All of this at a time when the new data reporting requirements
    resulting from the 2006 reauthorization of Ryan White are requiring
    even more staff and administrative time than the 10 percent allocation
    permitted.
        Frankly, we can do better than this and the HIV/AIDS population
    served through part C deserves more support. I have included the
    following graph in my testimony to demonstrate the growing disparity
    between funding for part C and our patient population. I call the gap
    between funding and patients the ``Triangle of Misery'' because it
    represents the thousands of patients who deserve more than we can offer
    them and the part C programs around the Nation who are struggling to
    serve them with rapidly shrinking resources.

        The purpose of my testimony is to urge you to respond to this
    crisis and ask that you commit to doubling funding for Ryan White Part
    C programs by fiscal year 2012. Through a careful process that
    determined the actual cost of our care for our patients, the Ryan White
    Medical Providers Coalition worked collaboratively with the CAEAR
    Coalition and the American Academy of HIV Medicine to calculate the
    funding demands for Ryan White Part C. We unanimously agreed that a
    Federal appropriation of $407,300,078 is needed for part C.
        These are challenging fiscal times, and we recognize the multiple
    fiscal constraints you face as you determine how to allocate limited
    Federal dollars. That is why we are not asking for $407.3 million for
    Ryan White Part C for fiscal year 2010. Rather, we join with our
    partners in asking you to commit to doubling our funding by fiscal year
    2012. Such an agreement would result in an increase of $68.4 million
    for part C for each year: fiscal years 2010, 2011, and 2012. We believe
    this is a reasonable approach to meeting the needs of HIV/AIDS patients
    served by part C around the country.
        It is important for you to understand how we developed our request
    number. It is based on the following calculations:
      --We assumed that 1,381,418 will be the number of people living with
            HIV/AIDS in 2012 based on the Centers for Disease Control and
            Prevention, New Estimates of HIV Prevalence, 2006. The estimate
            equals the CDC's 2006 estimated cases multiplied by their
            annual estimated prevalence increases for the years 2007-2012.
      --Using data from the HRSA HIV/AIDS Bureau we estimated that 248,070
            uninsured people living with HIV/AIDS were served by part C
            programs in 2008.
      --Using data from a report by Julie Gerberding, MD, MPH and Elizabeth
            Duke, Ph.D. to the Honorable Henry Waxman (http://
            oversight.house.gov/story.asp?ID1675) we estimated that 168,688
            PLWHA who were underinsured were served by part C programs in
            2008.
      --We estimate the cost of care per patient at $3,501 per year.
            (Gilman, BH, Green, JC. Understanding the variation in costs
            among HIV primary care providers. AIDS Care. 2008:20;1050-6.)
      --We calculated the cost of providing care to uninsured part C
            patients to be $277,916,382 per year (79,382 patients  $3,501
            cost of care).
      --We calculated the costs of providing care to underinsured part C
            patients to be $129,383,696 per year (168,688 patients  $767
            cost of care). The cost of care for underinsured patients is a
            conservative estimate based on Institute of Medicine figures.
      --The total cost of care for all part C patients will be $407,300,078
            in fiscal year 2012.
        Our data demonstrate the undeniable. Our patient load is increasing
    as is the cost of their care. A substantial Federal investment is
    necessary to support part C sites around the country in their efforts
    to provide the comprehensive care that we know HIV/AIDS patients
    deserve and from which both they and our communities benefit.
        I thank you for your attention to our request and urge you to
    commit to doubling the funding for Ryan White Part C in 3 years. We
    request a $68.4 million increase for part C for fiscal year 2010
    resulting in a total appropriation of $270,254,000. By working
    together, we are hopeful that in fiscal year 2012 the full
    appropriation for Ryan White Part C will be $407,300,078.
                                     ______

      Prepared Statement of the Spina Bifida Association and Spina Bifida
                                   Foundation
                            funding request overview
        The Spina Bifida Association (SBA) and the Spina Bifida Foundation
    (SBF) respectfully request that the subcommittee provide the following
    allocations in fiscal year 2010 to help improve quality-of-life for
    people with Spina Bifida:
      --$7 million for the National Spina Bifida Program at the National
            Center on Birth Defects and Developmental Disabilities at the
            Centers for Disease Control and Prevention (CDC) to support
            existing program initiatives and allow for the further
            development of the National Spina Bifida Patient Registry.
      --$4.818 million for the CDC's national folic acid education and
            promotion efforts to support the prevention of Spina Bifida and
            other neural tube defects.
      --$25.623 million to strengthen the CDC's National Birth Defects
            Prevention Network.
      --$77.059 million for the CDC's National Center on Birth Defects and
            Developmental Disabilities.
      --$405 million for the Agency for Healthcare Research and Quality
            (AHRQ).
      --$33.349 billion for the National Institutes of Health (NIH) to
            support biomedical research.
                           background on spina bifida
        On behalf of the more than 185,000 \1\ individuals and their
    families who are affected by Spina Bifida--the Nation's most common,
    permanently disabling birth defect--SBA and SBF appreciate the
    opportunity to submit written testimony for the record regarding fiscal
    year 2010 funding for the National Spina Bifida Program and other
    related Spina Bifida initiatives. SBA is a national voluntary health
    agency working on behalf of people with Spina Bifida and their families
    through education, advocacy, research and service. The Spina Bifida
    Foundation assists SBA in its fundraising and advocacy efforts. SBA and
    SBF stand ready to work with Members of Congress and other stakeholders
    to ensure our Nation mounts and sustains a comprehensive effort to
    reduce and prevent suffering from Spina Bifida.
    ---------------------------------------------------------------------------
        \1\ At the First World Congress on Spina Bifida Research and Care
    in March 2009 representatives from the CDC reported on new data
    indicating that there are an estimated 185,000 individuals living with
    Spina Bifida in the United States.
    ---------------------------------------------------------------------------
        Spina Bifida, a neural tube defect, occurs when the spinal cord
    fails to close properly within the first few weeks of pregnancy and
    most often before the mother knows that she is pregnant. Over the
    course of the pregnancy--as the fetus grows--the spinal cord is exposed
    to the amniotic fluid, which increasingly becomes toxic. It is believed
    that the exposure of the spinal cord to the toxic amniotic fluid erodes
    the spine and results in Spina Bifida. There are varying forms of Spina
    Bifida occurring from mild--with little or no noticeable disability--to
    severe--with limited movement and function. In addition, within each
    different form of Spina Bifida the effects can vary widely.
    Unfortunately, the most severe form of Spina Bifida occurs in 96
    percent of children born with this birth defect.
        The result of this neural tube defect is that most people with it
    suffer from a host of physical, psychological, and educational
    challenges--including paralysis, developmental delay, numerous
    surgeries, and living with a shunt in their skulls, which seeks to
    ameliorate their condition by helping to relieve cranial pressure
    associated with spinal fluid that does not flow properly. As we have
    testified previously, the good news is that after decades of poor
    prognoses and short life expectancy, children with Spina Bifida are now
    living into adulthood and increasingly into their advanced years. These
    gains in longevity, principally, are due to breakthroughs in research,
    combined with improvements generally in healthcare and treatment.
    However, with this extended life expectancy, our Nation and people with
    Spina Bifida now face new challenges--education, job training,
    independent living, healthcare for secondary conditions, and aging
    concerns, among others. Individuals and families affected by Spina
    Bifida face many challenges--physical, emotional, and financial.
    Fortunately, with the creation of the National Spina Bifida Program in
    2003, individuals and families affected by Spina Bifida now have a
    national resource that provides them with the support, information, and
    assistance they need and deserve.
        As is discussed below, the daily consumption of 400 micrograms of
    folic acid by women of childbearing age prior to becoming pregnant and
    throughout the first trimester of pregnancy can help reduce the
    incidence of Spina Bifida, by up to 70 percent. However, 1,500 babies
    are still born each year with Spina Bifida, and, as such, with the
    aging of the Spina Bifida population and a steady number of affected
    births annually, the Nation must take additional steps to ensure that
    all individuals living with this complex birth defect can live full,
    healthy, and productive lives.
                              cost of spina bifida
        It is important to note that the lifetime costs associated with a
    typical case of Spina Bifida--including medical care, special
    education, therapy services, and loss of earnings--are as much as $1
    million. The total societal cost of Spina Bifida is estimated to exceed
    $750 million per year, with just the Social Security Administration
    payments to individuals with Spina Bifida exceeding $82 million per
    year. Moreover, tens of millions of dollars are spent on medical care
    paid for by the Medicaid and Medicare programs. The emotional,
    financial, and physical toll and costs of Spina Bifida on the
    individuals and families affected are extraordinary. Efforts to reduce
    and prevent suffering from Spina Bifida will help to not only save
    money, but will also save--and improve--lives.
      improving quality-of-life through the national spina bifida program
        SBA has worked with Members of Congress to help improve our
    Nation's efforts to prevent Spina Bifida and diminish suffering--and
    enhance quality-of-life--for those currently living with this
    condition. With appropriate, affordable, and high-quality medical,
    physical, and emotional care, most people born with Spina Bifida likely
    will have a normal or near normal life expectancy. The CDC's National
    Spina Bifida Program works on two critical levels--to reduce and
    prevent Spina Bifida incidence and morbidity and to improve quality-of-
    life for those living with Spina Bifida. The program seeks to ensure
    that what is known by scientists is practiced and experienced by the
    individuals affected by Spina Bifida. Moreover, the National Spina
    Bifida Program works to improve the outlook for a life challenged by
    this complicated birth defect--principally, identifying valuable
    therapies from in-utero throughout the lifespan and making them
    available and accessible to those in need.
        The National Spina Bifida Program serves as a national center for
    information and support to help ensure that individuals, families, and
    other caregivers, such as health professionals, have the most up-to-
    date information about effective interventions for the myriad primary
    and secondary conditions associated with Spina Bifida. Among many other
    activities, the program helps individuals with Spina Bifida and their
    families learn how to treat and prevent secondary health problems, such
    as bladder and bowel control difficulties, learning disabilities,
    depression, latex allergies, obesity, skin breakdown and social and
    sexual issues. Children with Spina Bifida often have learning
    disabilities and may have difficulty with paying attention, expressing
    or understanding language, and grasping reading and math. All of these
    problems can be treated or prevented, but only if those affected by
    Spina Bifida--and their caregivers--are properly educated and taught
    what they need to know to maintain the highest level of health and
    well-being possible. The National Spina Bifida Program's secondary
    prevention activities represent a tangible quality-of-life difference
    to the 185,000 individuals living with Spina Bifida with the goal being
    living well with Spina Bifida.
        One way to enhance the knowledge base of Spina Bifida, improve
    quality of care, and save precious resources is to establish a patient
    registry for Spina Bifida. Plans are underway to create the National
    Spina Bifida Patient Registry. This registry is intended to determine
    the best clinical practices and the most cost-effective treatment for
    Spina Bifida, as well as, support the creation of quality measures to
    improve overall care. It is only through clinical research towards
    improved care that we can truly save lives, while also realizing a
    significant cost savings.
        In fiscal year 2009, SBA requested $7 million be allocated to
    support and expand the National Spina Bifida Program. In the final
    fiscal year 2009 Omnibus Appropriations Act, Congress provided $5.468
    million for this program, following 3 years of essentially flat
    funding. SBA understands that the Congress and the Nation face
    unprecedented budgetary challenges and, as such, appreciates this
    modest increase. However, the progress being made by the National Spina
    Bifida Program must be sustained and expanded to ensure that people
    with Spina Bifida--over the course of their lifespan--have the support
    and access to quality care they need and deserve. To that end, SBA
    respectfully urges the subcommittee to Congress allocate $7 million in
    fiscal year 2010 to the program so it can continue and expand its
    current scope of work; further develop the National Spina Bifida
    Patient Registry; and sustain the National Spina Bifida Resource
    Center. Increasing funding for the National Spina Bifida Program will
    help ensure that our Nation continues to mount a comprehensive effort
    to prevent and reduce suffering from--and the costs of--Spina Bifida.
                            preventing spina bifida
        While the exact cause of Spina Bifida is unknown, over the last
    decade, medical research has confirmed a link between a woman's folate
    level before pregnancy and the occurrence of Spina Bifida. Sixty-five
    million women of child-bearing age are at-risk of having a child born
    with Spina Bifida, and each year approximately 3,000 pregnancies in
    this country are affected by Spina Bifida, resulting in an estimated
    1,500 births. As mentioned above, the daily consumption of 400
    micrograms of folic acid prior to becoming pregnant and throughout the
    first trimester of pregnancy can help reduce the incidence of Spina
    Bifida, by up to 70 percent. There are few public health challenges
    that our Nation can tackle and conquer by nearly three-fourths in such
    a straightforward fashion. However, we must still be concerned with
    addressing the 30 percent of Spina Bifida cases that cannot be
    prevented by folic acid consumption, as well as ensuring that all women
    of childbearing age--particularly those most at-risk for a Spina Bifida
    pregnancy--consume adequate amounts of folic acid prior to becoming
    pregnant.
        The good news is that progress has been made in convincing women of
    the importance of folic acid consumption and the need to maintain a
    diet rich in folic acid. Since 1968, the CDC has led the Nation in
    monitoring birth defects and developmental disabilities, linking these
    health outcomes with maternal and/or environmental factors that
    increase risk, and identifying effective means of reducing such risks.
    This public health success should be celebrated, but still too many
    women of childbearing age consume inadequate daily amounts of folic
    acid prior to becoming pregnant, and too many pregnancies are still
    affected by this devastating birth defect. The Nation's public
    education campaign around folic acid consumption must be enhanced and
    broadened to reach segments of the population that have yet to heed
    this call--such an investment will help ensure that as many cases of
    Spina Bifida can be prevented as possible.
        SBA is the managing agent for the National Council on Folic Acid, a
    multi-sector partnership reaching more than 100 million people a year
    with the folic acid message. The goal is to increase awareness of the
    benefits of folic acid, particularly for those at elevated risk of
    having a baby with neural tube defects (those who have Spina Bifida
    themselves, or those who have already conceived a baby with Spina
    Bifida). With additional funding in fiscal year 2010, CDC's folic acid
    awareness activities could be expanded to reach the broader population
    in need of these public health education, health promotion, and disease
    prevention messages. SBA advocates that Congress provide additional
    funding to CDC to allow for a targeted public health education and
    awareness focus on at-risk populations (e.g., Hispanic-Latino
    communities) and health professionals who can help disseminate
    information about the importance of folic acid consumption among women
    of childbearing age.
        In addition to a $7 million fiscal year 2010 allocation for the
    National Spina Bifida Program, SBA urges the subcommittee to provide
    $4.818 million for the CDC's national folic acid education and
    promotion efforts to support the prevention of Spina Bifida and other
    neural tube defects; $25.623 million to strengthen the CDC's National
    Birth Defects Prevention Network; and a total of $77.059 million for
    the National Center on Birth Defects and Developmental Disabilities.
             improving healthcare for individuals with spina bifida
        As you know, AHRQ's mission is to improve the outcomes and quality
    of healthcare, reduce healthcare costs, improve patient safety,
    decrease medical errors, and broaden access to essential health
    services. AHRQ's work is vital to the evaluation of new treatments,
    which helps ensure that individuals living with Spina Bifida continue
    to receive state-of-the-art care and interventions. To that end, we
    request a $405 million fiscal year 2010 allocation for AHRQ, so it can
    continue to provide guidance and support to the National Spina Bifida
    Patient Registry.
             sustain and seize spina bifida research opportunities
        Our Nation has benefited immensely from our past Federal investment
    in biomedical research at the NIH. SBA joins with other in the public
    health and research community in advocating that NIH receive $33.349
    billion in fiscal year 2010. This funding will support applied and
    basic biomedical, psychosocial, educational, and rehabilitative
    research to improve the understanding of the etiology, prevention, cure
    and treatment of Spina Bifida and its related conditions. In addition,
    SBA respectfully requests that the subcommittee include language in the
    report accompanying the fiscal year 2010 Labor, Health and Human
    Services, and Education, and related Agencies appropriations measure:
      --Urging the National Institute of Child Health and Human Development
            to continue to support--and expand--a more comprehensive Spina
            Bifida research portfolio that focuses on addressing the myriad
            secondary effects and conditions associated with Spina Bifida;
      --Commending the National Institute of Diabetes and Digestive and
            Kidney Diseases for its interest in exploring issues related to
            the neurogenic bladder and to encourage the Institute to forge
            ahead with its work in this important topic area; and
      --Encouraging the National Institute of Neurological Diseases and
            Stroke to continue and expand its research related to the
            treatment and management of hydrocephalus.
                                   conclusion
        Please know that SBA and SBF stand ready to work with the
    subcommittee and other Members of Congress to advance policies and
    programs that will reduce and prevent suffering from Spina Bifida.
    Again, we thank you for the opportunity to present our views regarding
    fiscal year 2010 funding for programs that will improve the quality-of-
    life for the 185,000 Americans and their families living with Spina
    Bifida.
                                     ______

                Prepared Statement of the Scleroderma Foundation
        Mr. Chairman, I am Cynthia Cervantes, I am 12 and in the ninth
    grade. I live in southern California and in October 2006 I was
    diagnosed with scleroderma. Scleroderma means ``hard skin'' which is
    literally what scleroderma does and, in my case, also causes my
    internal organs to stiffen and contract. This is called diffuse
    scleroderma. It is a relatively rare disorder effecting only about
    300,000 Americans.
        About 2 years ago I began to experience sudden episodes of
    weakness, my body would ache and my vision was worsening, some days it
    was so bad I could barely get myself out of bed. I was taken to see a
    doctor after my feet became so swollen that calcium began to ooze out.
    It took the doctors (period of time) to figure out exactly what was
    wrong with me, because of how rare scleroderma is.
        There is no known cause for scleroderma, which affects three times
    as many women as men. Generally, women are diagnosed between the ages
    of 25 and 45, but some kids, like me, are affected earlier in life.
    There is no cure for scleroderma, but it is often treated with skin
    softening agents, anti-inflammatory medication, and exposure to heat.
    Sometimes a feeding tube must be used with a scleroderma patient
    because their internal organs contract to a point where they have
    extreme difficulty digesting food.
        The Scleroderma Foundation has been very helpful to me and my
    family. They have provided us with materials to educate my teachers and
    others about my disease. Also, the support groups the foundation helps
    organize are very helpful because they help show me that I can live a
    normal, healthy life, and how to approach those who are curious about
    why I wear gloves, even in hot weather. It really means a lot to me to
    be able to interact with other people in the same situation as me
    because it helps me feel less alone.
        Mr. Chairman, because the causes of scleroderma are currently
    unknown and the disease is so rare, and we have a great deal to learn
    about it in order to be able to effectively treat it. I would like to
    ask you to please significantly increase funding for the National
    Institute of Health (NIH) so treatments can be found for other people
    like me who suffer from scleroderma. It would also be helpful to start
    a program at the Centers for Disease Control and Prevention to educate
    the public and physicians about scleroderma.
             overview of the scleroderma foundation and scleroderma
    Scleroderma Foundation
        The Scleroderma Foundation is a nonprofit organization based in
    Danvers, Massachusetts with a three-fold mission of support, education,
    and research. The Foundation has 21 chapters nationwide and more than
    175 support groups.
        The Scleroderma Foundation was established on January 1, 1998
    through a merger between two organizations, one on the west coast and
    one on the east coast, which can trace their beginnings back to the
    early 1970s. The Foundation's mission is to provide support for people
    living with scleroderma and their families through programs such as
    peer counseling, doctor referrals, and educational information, along
    with a toll-free telephone helpline for patients and a quarterly
    magazine, The Scleroderma Voice.
        The Foundation also provides education about the disease to
    patients, families, the medical community, and the general public
    through a variety of awareness programs at both the local and national
    levels. More than $1 million in peer-reviewed research grants are
    awarded annually to institutes and universities to stimulate progress
    in the search for a cause and cure for scleroderma. Building awareness
    of the disease to patients, families, the medical community, and the
    general public to not only generate more funding for medical research,
    but foster a greater understanding of the complications faced by people
    living with the disease is a further major focus.
        Among the many programs arranged by the Foundation is the Annual
    Patient Education Conference held each summer. The conference brings
    together an average of 500 attendees and experts for a wide range of
    workshops on such topics as the latest research initiatives, coping and
    disease management skills, caregiver support, and exercise programs.
    Scleroderma Overview
        Scleroderma is an autoimmune disease which means that it is a
    condition in which the body's immune system attacks its own tissues. In
    autoimmune disorders, this ability to distinguish foreign from self is
    compromised. As immune cells attack the body's own tissue, inflammation
    and damage result. Scleroderma (the name means ``hard skin'') can vary
    a great deal in terms of severity. For some, it is a mild condition;
    for others it can be life threatening. Although there are medications
    to slow down disease progression and help with symptoms, there is as
    yet no cure for scleroderma.
    Who Gets Scleroderma?
        There are many clues that define susceptibility to develop
    scleroderma. A genetic basis for the disease has been suggested by the
    fact that it is more common among patients whose family members have
    other autoimmune diseases (such as lupus). In rare cases, scleroderma
    runs in families, although for the vast majority of patients there is
    no other family member affected. Some Native Americans and African
    Americans get worse scleroderma disease than Caucasians.
        Women are more likely to get scleroderma. Environmental factors may
    trigger the disease in the susceptible host. Localized scleroderma is
    more common in children, whereas scleroderma is more common in adults.
    However, both can occur at any age.
        There are an estimated 300,000 people in the United States who have
    scleroderma, about one-third of whom have the systemic form of
    scleroderma. Diagnosis is difficult and there may be many misdiagnosed
    or undiagnosed cases as well.
        Scleroderma can develop and is found in every age group from
    infants to the elderly, but its onset is most frequent between the ages
    of 25 to 55. There are many exceptions to the rules in scleroderma,
    perhaps more so than in other diseases. Each case is different.
    Causes of Scleroderma
        The cause is unknown. However, we do understand a great deal about
    the biological processes involved. In localized scleroderma, the
    underlying problem is the overproduction of collagen (scar tissue) in
    the involved areas of skin. In systemic sclerosis, there are three
    processes at work: blood vessel abnormalities, fibrosis (which is
    overproduction of collagen) and immune system dysfunction, or
    autoimmunity.
                                    research
        Research suggests that the susceptible host for scleroderma is
    someone with a genetic predisposition to injury from some external
    agent, such as a viral or bacterial infection or a substance in the
    diet or environment. In localized scleroderma, the resulting damage is
    confined to the skin. In systemic sclerosis, the process causes injury
    to blood vessels, or indirectly perturbs the blood vessels by
    activating the immune system.
        Research continues to assemble the pieces of the scleroderma puzzle
    to identify the susceptibility genes, to find the external trigger and
    cellular proteins driving fibrosis, and to interrupt the networks that
    perpetuate the disease.
                              types of scleroderma
        There are two main forms of scleroderma: systemic (systemic
    sclerosis, SSc) that usually affects the internal organs or internal
    systems of the body as well as the skin, and localized that affects a
    local area of skin either in patches (morphea) or in a line down an arm
    or leg (linear scleroderma), or as a line down the forehead
    (scleroderma en coup de sabre). It is very unusual for localized
    scleroderma to develop into the systemic form.
    Systemic Sclerosis
        There are two major types of systemic sclerosis (SSc)--limited
    cutaneous SSc and diffuse cutaneous SSc. In limited SSc, skin
    thickening only involves the hands and forearms, lower legs, and feet.
    In diffuse cutaneous disease, the hands, forearms, the upper arms,
    thighs, or trunk are affected.
        The face can be affected in both forms. The importance of making
    the distinction between limited and diffuse disease is that the extent
    of skin involvement tends to reflect the degree of internal organ
    involvement.
        Several clinical features occur in both limited and diffuse
    cutaneous SSc. Raynaud's phenomenon occurs in both. Raynaud's
    phenomenon is a condition in which the fingers turn pale or blue upon
    cold exposure, and then become ruddy or red upon warming up. These
    episodes are caused by a spasm of the small blood vessels in the
    fingers. As time goes on, these small blood vessels become damaged to
    the point that they are totally blocked. This can lead to ulcerations
    of the fingertips.
        People with the diffuse form of SSc are at risk of developing
    pulmonary fibrosis (scar tissue in the lungs that interferes with
    breathing, also called interstitial lung disease), kidney disease, and
    bowel disease.
        The risk of extensive gut involvement, with slowing of the movement
    or motility of the stomach and bowel, is higher in those with diffuse
    rather than limited SSc. Symptoms include feeling bloated after eating,
    diarrhea, or alternating diarrhea and constipation.
        Calcinosis refers to the presence of calcium deposits in, or just
    under, the skin. This takes the form of firm nodules or lumps that tend
    to occur on the fingers or forearms, but can occur anywhere on the
    body. These calcium deposits can sometimes break out to the skin
    surface and drain whitish material (described as having the consistency
    of toothpaste).
        Pulmonary Hypertension (PH) is high blood pressure in the blood
    vessels of the lungs. It is totally independent of the usual blood
    pressure that is taken in the arm. This tends to develop in patients
    with limited SSc after several years of disease. The most common
    symptom is shortness of breath on exertion. However, several tests need
    to be done to determine if PH is the real culprit. There are now many
    medications to treat PH.
    Localized Scleroderma
                Morphea
        Morphea consists of patches of thickened skin that can vary from
    one-half inch to 6 inches or more in diameter. The patches can be
    lighter or darker than the surrounding skin and thus tend to stand out.
    Morphea, as well as the other forms of localized scleroderma, does not
    affect internal organs.
                Linear scleroderma
        Linear scleroderma consists of a line of thickened skin down an arm
    or leg on one side. The fatty layer under the skin can be lost, so the
    affected limb is thinner than the other one. In growing children, the
    affected arm or leg can be shorter than the other.
                Scleroderma en coup de sabre
        Scleroderma en coup de sabre is a form of linear scleroderma in
    which the line of skin thickening occurs on the forehead or elsewhere
    on the face. In growing children, both linear scleroderma and en coup
    de sabre can result in distortion of the growing limb or lack of
    symmetry of both sides of the face.
                fiscal year 2010 appropriations recommendations
        A 7 percent overall increase for NIH.
        A 7 percent increase for the National Institute of Arthritis and
    Musculoskeletal and Skin Diseases (NIAMS) at the NIH.
        A subcommittee recommendation encouraging NIAMS to support a State
    of the Science Conference on Scleroderma in fiscal year 2010.
        Subcommittee recommendation encouraging the Centers for Disease
    Control and Prevention to partner with the Scleroderma Foundation to
    promoting increased awareness of scleroderma among the general public
    and healthcare providers.
                                     ______

       Prepared Statement of the Society for Healthcare Epidemiology of
                                    America
        Society for Healthcare Epidemiology of America (SHEA) was founded
    in 1980 to advance the application of the science of healthcare
    epidemiology. SHEA works to achieve the highest quality of patient care
    and healthcare personnel safety in all health care settings by applying
    epidemiologic principles and prevention strategies to a wide range of
    quality-of-care issues. SHEA is a growing organization, strengthened by
    its membership in all branches of medicine, public health, and
    healthcare epidemiology.
        SHEA and its members are committed to implementing evidence-based
    strategies to prevent healthcare-associated infections (HAIs). SHEA
    members have scientific expertise in evaluating potential strategies
    for eliminating preventable HAIs. We collaborate with a wide range of
    infection prevention and infectious disease societies, specialty
    medical societies in other fields, quality improvement organizations,
    and patient safety organizations in order to identify and disseminate
    evidence-based practices.
        Our principal partners in the private sector are sister societies
    such as the Infectious Diseases Society of America and the Association
    of Professionals in Infection Control and Epidemiology. The Centers for
    Disease Control and Prevention (CDC), its Division of Healthcare
    Quality Promotion (DHQP) and the Federal Healthcare Infection Practices
    Advisory Committee (HICPAC), and the Council of State and Territorial
    Epidemiologists have been invaluable Federal partners in the
    development of guidelines for the prevention and control of HAIs and in
    their support of translational research designed to bring evidence-
    based practices to patient care. Further, collaboration between experts
    in the field (epidemiologists and infection preventionists), CDC and
    the Agency for Healthcare Research and Quality (AHRQ) plays a critical
    role in defining and prioritizing the research agenda. More recently,
    SHEA has aligned with the Joint Commission and the American Hospital
    Association to produce and promote the implementation of evidence-based
    recommendations in the Compendium of Strategies to Prevent Healthcare-
    Associated Infections in Acute Care Hospitals (http://www.shea-
    online.org/about/compendium.cfm). The organization also contributes
    expert scientific advice to quality improvement organizations such as
    the Institute for Healthcare Improvement (IHI), the National Quality
    Forum, and State-based task forces focused on infection prevention and
    public reporting issues.
        The current swine flu emergency and the Obama administration's
    request for an additional $1.5 billion to address the situation
    highlights the need for ongoing congressional support of a national
    prevention strategy and dedicated funding stream for core public health
    programs. It is our hope that health reform can serve as an opportunity
    to strengthen our public health infrastructure and reorient our health
    system towards prevention and preparedness.
        SHEA applauds the Congress for its support of HAI prevention and
    reduction activities through the American Recovery and Reinvestment Act
    (ARRA) and the fiscal year 2009 Omnibus Appropriations bill. The
    Society is collaborating with the Department of Health and Human
    Services (HHS) and the CDC to translate agency goals and objectives for
    these funds into actions at the bedside that can achieve meaningful
    reductions in preventable HAIs. However, SHEA believes that this level
    of funding is substantially insufficient to address a problem estimated
    by CDC to be one of the top 10 causes of death in the Nation and one
    that poses a significant economic burden on the Nation's healthcare
    system.
        SHEA supports the conclusions of last year's GAO report on
    coordination among HHS agencies related to HAI prevention. We believe
    that coordinated action among CDC, the Centers for Medicare and
    Medicaid Services (CMS) and AHRQ is critical. CDC and its DHQP should
    function as the lead agency in surveillance and prevention activities
    related to HAIs at the Federal level because of its historic and
    successful role in this area. CDC has had an enviable track record of
    prevention and its development and management of the foremost
    surveillance system of its kind, the National Healthcare Safety Network
    (NHSN) has created a national resource that many States have now
    mandated as their public reporting tool. Furthermore, guidelines
    developed by the HICPAC are widely regarded as the standards for the
    field. Coordinated activity among the agencies can lead to better
    informed public policy and payment reform.
        Clearly, the CDC plays a critical role in public health protection
    through its health promotion, prevention, preparedness, and research
    activities. As you consider fiscal year 2010 funding levels for the
    CDC, SHEA urges your support of at least $8.6 billion for CDC's ``core
    programs'' (not including the mandatory funding provided for the
    Vaccines for Children Program) to ensure that the agency is able to
    carry out its prevention mission and to assure an adequate translation
    of new research into effective State and local programs. In addition to
    maintaining a strong public health infrastructure and protecting
    Americans from public health threats and emergencies, SHEA strongly
    believes that CDC programs play a vital role in reducing healthcare
    costs and improving the public's health.
        Within this total, SHEA recommends a fiscal year 2010 funding level
    of $2.4 billion for CDC's Infectious Diseases program budget which
    supports vital management and coordination functions for infectious
    disease science, program, and policy, including infectious disease
    specific epidemiology and laboratory activities. In particular, SHEA
    believes that protecting and improving resources for implementation of
    programs that standardize measurement of appropriate HAI outcomes and
    performance measures should be a priority. Our most valuable resource
    in this regard is NHSN, a voluntary, secure, Internet-based
    surveillance system that integrates and expands patient and healthcare
    personnel safety surveillance systems. Many States consider NHSN to be
    the best option for implementing standardized reporting of HAI data.
    NHSN has now been adopted by 19 States and more than 2,100 U.S.
    hospitals for the surveillance and reporting of HAIs. It is an
    enormously important national resource and effective funding and
    support is essential to expand its implementation. Further, recognizing
    that multiple States mandate the use of NHSN for State public
    reporting, immediate efforts should be made to enable interfaces
    between electronic health records and NHSN. In this way, additional
    burdens are not placed upon healthcare entities from either an
    infection prevention and control or information technology perspective
    as the desirability for national database integration proceeds.
        As already noted, SHEA believes that additional Federal dollars
    should be appropriated for HAI prevention and reduction to build upon
    the investment already made through the ARRA and fiscal year 2009
    omnibus appropriations bill. It is SHEA's perspective that additional
    funding in this area will have the greatest impact when prioritized in
    the following ways:
      --SHEA strongly encourages an emphasis on implementation of evidence-
            based practices, as supported by guidelines (CDC-HICPAC) and
            evidence-based recommendations (Compendium of Strategies to
            Prevent Healthcare-Associated Infections in Acute Care
            Hospitals). Protecting the health of our patients and
            preventing HAIs in the settings where healthcare is delivered
            in the United States will require a multi-faceted approach that
            includes identification and widespread adoption of evidence-
            based best practices. Where evidence does not exist, uniformity
            in practice should be adopted and studied to determine
            effectiveness. Failed practices should be discarded and
            successes widely disseminated. Prevention and control of HAIs
            also will require better tools in the form of new and novel
            antimicrobial agents, better knowledge of strategies to effect
            implementation and adherence to proven prevention methods, and
            accountability for performance.
      --SHEA supports investment in training and education programs for
            both hospital-wide personnel, local public health personnel and
            patients/families in evidence-based prevention practices and
            development of educational materials /tools for patients and
            families with respect to HAI and multiple drug resistant
            organisms (MDRO).
      --SHEA supports a broad context for use of dollars for HAIs rather
            than pathogen-specific targets or mandates (e.g., on MRSA or C.
            difficile). Ideally, funding should be tied to locally
            identified priorities emphasizing that implementation of best
            practice bundles for catheter-associated bloodstream infections
            (CLA-BSI), ventilator-associated pneumonia and catheter-
            associated urinary tract infection (CA-UTI) will have a greater
            impact on prevention of HAIs, including those due to MDRO, than
            pathogen-specific practices. This approach recognizes the
            influence of local conditions on the control of healthcare-
            associated infections, and allows rapid modification of
            strategies as new knowledge is gained. As an example, SHEA and
            CMS emphasize that a risk assessment must be the first step in
            any epidemiologic study or infection prevention and control
            program in order to target preventive efforts effectively. We
            are pleased that the Joint Commission supports this critical
            step by developing it into a basic infection prevention
            standard. SHEA believes that this strategy allows healthcare
            facilities to use local information to develop and implement
            optimal and individualized prevention plans designed to reduce
            healthcare-associated infections that are identified as local
            problems. Goals should be written in such a way to allow
            hospitals the flexibility to identify and target their own
            safety threats within the domains that are considered critical,
            and healthcare facilities should be expected to be able to
            justify their infection prevention program based on local risk
            assessments.
      --SHEA supports investment in hospital infrastructure and qualified
            personnel for infection prevention and control including
            epidemiologists, infection prevention and control
            professionals, NHSN implementation, and adequate microbiology/
            lab diagnostic capability as dictated by locally derived needs
            assessment and priority.
      --SHEA believes that funds made available through CDC and AHRQ should
            be used, in part, for translational research projects that can
            allow more rapid integration of science into practice. As an
            example, this could involve use of funds to support positions
            through which large collaboratives could be supported in States
            not currently part of AHRQ or HRET projects (for example PHRI
            and Keystone, which have achieved successful reductions in
            device-associated infections). Experts in the field
            (Epidemiologists and Infection Preventionists), in
            collaboration with CDC and the AHRQ, should be engaged in order
            to further define and prioritize the research agenda. As we
            strive to eliminate all preventable HAIs, we need to identify
            the gaps in our understanding of what is actually preventable.
            This distinction is critical to help guide subsequent research
            priorities and to help set realistic expectations. SHEA
            believes in the importance of conducting basic, epidemiological
            and translational studies (to fill basic and clinical science
            gaps). While health services research (i.e., successful
            implementation of strategies already known or suspected to be
            beneficial) may provide some immediate short-term benefit, to
            achieve further success, a substantial investment in basic
            science, translational medicine, and epidemiology is needed to
            permit effective and precise, interventions that prevent HAIs.
      --SHEA strongly favors local decision-making about priorities for use
            of funds; however, State efforts should be aligned with CDC
            priorities and should be carried out through collaboration with
            key stakeholders such as State hospital associations and local
            experts. CDC should lead the effort to measure and report on
            the success of State prevention efforts to HHS.
        With respect to the National Institutes of Health (NIH), SHEA is
    very pleased that the ARRA infused the Institutes with billions of
    dollars for research projects that will enable growth and investment in
    biomedical research and development, public health and healthcare
    delivery. The NIH is the single-largest funding source for infectious
    diseases research in the United States and the life-source for many
    academic research centers. The NIH-funded work conducted at these
    centers lays the ground work for advancements in treatments, cures, and
    medical technologies. We applaud Congress for acknowledging the impact
    of scientific research in stimulating the economy.
        SHEA believes that any national effort designed to address the
    problem of HAIs should begin with the following principles: scrutiny of
    the science base; development of an aggressive, prioritized research
    agenda; the conduct of studies that address the identified questions;
    creation and deployment of guidelines based on the outcomes of these
    studies, followed by studies that assess the efficacy of the
    intervention.
        In order to determine the preventability of infections, we first
    need to understand how and why these infections occur. A comprehensive
    national research agenda on HAIs must include at least three major
    categories of research: pathogenesis, epidemiology, and infection
    prevention strategies. A fourth area of, perhaps, even greater
    importance is the development and use of improved approaches to the
    design of healthcare epidemiology studies. Carefully designed
    multicenter prospective clinical trials are needed to establish the
    effectiveness of prevention and control strategies.
        Unfortunately, support for basic, translational, and
    epidemiological research on HAIs has not been a priority of major
    funding bodies. Despite the fact that HAIs are among the top 10 annual
    causes of death in the United States, scientists studying these
    infections have received relatively less funding than colleagues in
    many other disciplines. In 2008, NIH estimated that it spent more than
    $2.9 billion dollars on funding for HIV/AIDS research, about $2 billion
    on cardiovascular disease research, about $664 million on obesity
    research and, by comparison, National Institute of Allergy and
    Infectious Diseases provided $18 million for MRSA research. SHEA
    believes that as the magnitude of the HAI problem becomes part of the
    dialogue on healthcare reform, it is imperative that the Congress and
    funding organizations put significant resources behind this momentum.
        The limited availability of Federal funding to study HAIs has the
    effect of steering young investigators interested in pursuing research
    on HAIs toward other, better-funded fields. While industry funding is
    available, the potential conflicts of interest, particularly in the
    area of infection-prevention technologies, make this option seriously
    problematic. These challenges are limiting professional interest in the
    field and hampering the clinical research enterprise at a time when it
    should be expanding.
        Our discipline is faced with the need to bundle, implement, and
    adhere to interventions we believe to be successful while
    simultaneously conducting basic, epidemiological, pathogenetic, and
    translational studies that are needed to move our discipline to the
    next level of evidence-based patient safety. The current convergence of
    scientific, public, and legislative interest in reducing rates of HAIs
    can provide the necessary momentum to address and answer important
    questions in HAI research. SHEA strongly urges you to enhance NIH
    funding for fiscal year 2010 to ensure adequate support for the
    research foundation that holds the key to addressing the multifaceted
    challenges presented by HAIs.
        SHEA thanks for the subcommittee for this opportunity to share our
    priorities with respect to fiscal year 2010 funding for HHS, CDC, and
    the NIH. SHEA is pleased to serve as a resource to the subcommittee
    going forward on issues related to healthcare epidemiology.
                                     ______

         Prepared Statement of the Society for Maternal-Fetal Medicine
        Mr. Chairman and members of the subcommittee: The Society for
    Maternal-Fetal Medicine (SMFM) is pleased to have the opportunity to
    submit testimony in support of the fiscal year 2010 budget for the
    National Institute of Child Health and Human Development (NICHD).
        Established in 1977, SMFM is dedicated to improving maternal and
    child outcomes; and raising the standards of prevention, diagnosis, and
    treatment of maternal and fetal disease.
                                     issue
        Preterm birth is a major public health priority and a major
    research priority for NICHD.
      --Nearly 500,000 babies born in the United States (1 of every 8
            births) are preterm and the number continues to rise.
      --The annual cost due to preterm birth in the United States is
            estimated to be $26 billion.
      --These infants are at high risk for a variety of disorders including
            mental retardation, cerebral palsy and vision impairment.
      --They are also at high risk for long-term health issues including
            heart attack, stroke, and diabetes.
        NICHD has been given the mandate of supporting almost all research
    into maternal, child, and fetal health problems. In 1986, the NICHD
    established the Maternal Fetal Medicine Units Network to achieve a
    greater understanding and pursue development of effective treatments
    for the prevention of preterm births, intrauterine fetal growth
    disorders, and medical complications during pregnancy. The Network
    currently funds 14 university-based clinical centers and one data
    coordinating center, located around the country. Each site is funded
    for 5 years and is renewed by open competition. The advantages of doing
    clinical trials within the Network include: having large populations
    with which to conduct studies (there are approximately 120,000 births
    per year within the Network); provides diverse populations across an
    array of ethnic and socioeconomic backgrounds--as a result, the study
    outcomes are more likely to prove effective in real-world clinical
    practice.
        The Network has made a number of landmark contributions to
    obstetric practice. In particular, NICHD-supported research identified
    progesterone as a medication that can reduce premature deliveries
    significantly, and now patients are benefiting from this treatment.
    Another major advance is the use of magnesium sulfate--a common
    treatment to delay labor--to reduce the risk of cerebral palsy in
    preterm infants.
        Building on information gathered in previous Network studies, the
    Network is currently addressing whether progesterone will also prevent
    preterm birth in first pregnancies found to have a short cervix. We
    have learned that:
      --one of the largest segments of women at risk for preterm births are
            those having their first child.
      --when an ultrasound exam shows a short cervix (the opening of a
            woman's uterus), the risk of preterm birth is much higher.
      --progesterone injections reduce the risk for those women with a
            prior preterm birth.
        If benefit can be shown, progesterone will then be an intervention
    for prematurity prevention to apply to the largest segment of pregnant
    women at risk for preterm birth.
        While we are making progress, there are still many areas about
    maternal health, pregnancy, fetal well-being, labor, and delivery and
    the developing child that NICHD investigators must understand better.
    For example:
      --Steroids for the prevention of respiratory distress syndrome (RDS)
            and neonatal complications in the late preterm infant (34-37
            weeks).
      --Evaluation of the STAN monitor as an adjunct to intrapartum fetal
            monitoring to improve outcome of labor.
        However these areas are not being pursued due to a projected
    limited budget.
        We urge the subcommittee, as you move forward with your
    deliberations on the fiscal year 2010 budget, to provide greater
    resources to National Institutes of Health and in particular to the
    NICHD. Without a substantial increase and sustained investment in the
    critical medical research being conducted by the NICHD, therapies and
    preventive strategies that have a significant impact on the health of
    mothers and their babies will be delayed.
                                 recommendation
        SMFM recommends that Congress provide at least a 7 percent increase
    more than the fiscal year 2009 budget for NICHD in fiscal year 2010.
        Within the funds appropriated to the NICHD, SMFM urges Congress to
    instruct NICHD to adequately fund the Maternal Fetal Medicine Units
    Network.
        Thank you for the opportunity to submit our concerns to the
    subcommittee.
                                     ______

        Prepared Statement of the Society of Teachers of Family Medicine
        Mr. Chairman, the Society of Teachers of Family Medicine, the
    Association of Departments of Family Medicine, the Association of
    Family Medicine Residency Directors, and the North American Primary
    Care Research Group thank you for the opportunity to provide this
    testimony in support of funding for family medicine training in health
    professions training, the Agency for Healthcare Research and Quality
    (AHRQ) and the National Institutes of Health (NIH).
           healthcare reform requires a robust primary care workforce
        Healthcare reform without measures to address the need for more
    primary care physicians will never be comprehensive or effective; it
    will not be able to help the most vulnerable populations, and it will
    not address the significant cost and quality issues currently so
    problematic in the United States. Increased access for patients in
    terms of insurance coverage is critical, but not sufficient to resolve
    the growing shortage of primary care physicians. In fact increased
    coverage, without increased numbers of primary care physicians, is a
    recipe for disaster.
        Solving the problem of the primary care crisis requires a multi-
    faceted solution. One key element is to increase the value of primary
    care, both in terms of payment rates and loan forgiveness, and through
    other avenues to make primary care an attractive specialty choice for
    medical students. A second is to change the incentives and rules
    surrounding training under the Medicare graduate medical education
    system. A third is to increase funding of programs that are effective
    in producing more primary care physicians, such as the primary care
    medicine and dentistry cluster of the health professions training
    programs. And the fourth is to support research regarding the clinical
    needs of most people seeking care, relating to the most common acute,
    chronic, and comorbid conditions routinely cared for by primary care
    physicians.
        It is the latter two building blocks: funding for primary care
    physician training programs and funding for primary care research that
    come under this subcommittee's jurisdiction and that this testimony
    addresses
    Health Professions: Primary Care Medicine and Dentistry (title VII,
            section 747)
        We recommend that Congress build on the investment in primary care
    medicine training made in the American Recovery and Reinvestment Act
    (ARRA) by providing an appropriation of $215 million for primary care
    medicine and dentistry health professions training grants. The fiscal
    year 2009 omnibus appropriations bill only provided $500,000 more for
    these programs than in fiscal year 2008. This funding level ($48.4
    million) is less than half of the funding these programs received in
    fiscal year 2003. We appreciate your efforts in that the House had
    proposed to double that account in the ARRA. We applaud the $300
    million included for the National Health Service Corps, but we do not
    know how the remaining $200 million in workforce funds will be
    distributed between the many other workforce programs included in the
    ARRA.
           key advisory committees know these programs are effective
        The Institute of Medicine (IOM) calls the title VII program an
    ``undervalued asset.'' Title VII, section 747, administered by HRSA, is
    the only program aimed directly at training primary care physicians. On
    December 12, 2008, the Institute of Medicine released ``HHS in the 21st
    Century: Charting a New Course for a Healthier America,'' which points
    to the drastic decline in title VII funding. Within that report, the
    IOM terms title VII an ``undervalued asset.
        The HRSA Advisory Committee on Training in Primary Care Medicine
    and Dentistry \1\ recommends an annual minimum level of $215 million
    for the title VII, section 747 grant program. The Committee reasoned
    that:
    ---------------------------------------------------------------------------
        \1\ The Role of Title VII, Section 747 in Preparing Primary Care
    Practitioners to Care for the Underserved and Other High-Risk Groups
    and Vulnerable Populations. Sixth Annual Report to the Secretary of the
    U.S. Department of Health and Human Services and to Congress.

        Title VII funds are essential to support major primary care
    training programs that train the providers who work with vulnerable
    populations . . . additional funding is also necessary to prepare
    current and future primary care providers for their critical role in
    responding to healthcare challenges including demographic changes in
    the population, increased prevalence of chronic conditions, decreased
    access to care, and a need for effective first-response strategies in
    ---------------------------------------------------------------------------
    instances of acts of terrorism or natural disasters.

        The Congressional Research Service also found that reduced funding
    for the primary care medicine and dentistry cluster had a deleterious
    impact on the effectiveness of these programs--at a time when more,
    rather than less primary care is needed. For example, ``In fiscal year
    2006, the program supported a total of 17,870 individuals in clinical
    training in underserved areas, a decrease from the support of 31,153
    individuals in fiscal year 2005.'' \2\ This is a decrease of almost 43
    percent, in only 1 year.
    ---------------------------------------------------------------------------
        \2\ CRS Report to Congress. February 7, 2008 Title VII Health
    Professions Education and Training: Issues in Reauthorization (Order
    Code RL32546).
    ---------------------------------------------------------------------------
        A study in the Annals of Family Medicine (September/October 2008)
    shows that medical schools that receive primary care training dollars
    produce more physicians who work in Community Health Centers (CHCs) and
    serve in the National Health Service Corps compared to schools without
    title VII primary care funding. In spite of an effort to double the
    capacity of CHCs between 2002 and 2006, CHCs have found it difficult to
    recruit a sufficient number of primary care physicians and have
    hundreds of vacant positions.
        programs are economic drivers of cost-savings and higher quality
        A Health Affairs (April 2004) article found a lower quality of care
    in States with higher levels of Medicare spending. The authors from the
    Dartmouth Center for the Evaluative Clinical Sciences found that States
    with more specialists and fewer primary care physicians had
    significantly higher costs and lower quality. A small increase in the
    number of primary care physicians in a State was associated with a
    large boost in that State's quality ranking. Indeed, States at the 75th
    percentile in number of primary care physicians per capita recorded
    Medicare costs $1,600 less per Medicare beneficiary per year and
    higher-quality indicators than States at the 25th percentile. If all
    States were to move to this level of primary care services, higher-
    quality care could be delivered at a savings of $60 billion or more per
    year for Medicare patients alone. Increased funding for title VII,
    section 747 could train more family doctors to be available to provide
    this much needed high-quality, lower-cost care.
        The Government Accountability Office (GAO) and the Medicare Payment
    Advisory Commission have noted research indicating that access to
    primary care is associated with better health outcomes and lower
    healthcare costs. The GAO states ``Ample research in recent years
    concludes that the nation's over reliance on specialty care services at
    the expense of primary care leads to a healthcare system that is less
    efficient. At the same time, research shows that preventive care, care
    coordination for the chronically ill, and continuity of care--all
    hallmarks of primary care medicine--can achieve improved outcomes and
    cost savings.'' \3\
    ---------------------------------------------------------------------------
        \3\ Testimony before the Committee on Health, Education, Labor, and
    Pensions, U.S. Senate. Primary Care Professionals: Recent Supply
    Trends, Projections and Valuation of Services. Statement of A. Bruce
    Steinwald, Director Health Care, United States Accountability Office.
    February 12, 2008 GAO-08-472T.
    ---------------------------------------------------------------------------
        According to a report prepared by the National Association of
    Community Health Centers, The Robert Graham Center, and Capitol
    Link,\4\ ``There is a growing consensus among the Nation's political
    and industry leaders that the U.S. health care crisis has shifted from
    the realm of the poor and disenfranchised, to the doorstep of middle-
    class America.'' Additionally, they cite the following:
    ---------------------------------------------------------------------------
        \4\ Access Granted: The Primary Care Payoff, August 2007, National
    Association of Community Health Centers, The Robert Graham Center,
    Capitol Link (pgs 1-2).

        ``If every American made use of primary care, the healthcare system
    would see $67 billion in savings annually. This reflects not only those
    who do not have access to primary care, but also those who rely
    extensively on costly specialists for most of their care, leading to
    inefficiencies in the system. More specifically, the expansion of
    Medical homes can even more dramatically facilitate effective use of
    health care, improve health outcomes, minimize health disparities, and
    ---------------------------------------------------------------------------
    lower overall costs of care.''

        Another study by the Robert Graham Center,\5\ found that the
    economic impact of one family physician to his or her community was
    just more than $900,000 annually. Family physicians are the specialty
    most widely distributed throughout the United States. Using the data
    from their study on the economic impact of family physicians in their
    communities, they estimate that family physicians generate a nationwide
    economic impact of more than $46 billion per year. This is a
    conservative estimate, and does not include a number of intangible and
    other tangible economic benefits of family physicians, such as their
    contribution to the generation of income for other local healthcare
    organizations such as hospitals and nursing homes. In addition, while
    most medical specialties tend to cluster in urban areas and near
    academic health centers, family physicians are the specialists that are
    most likely to work in the poorest rural and urban areas. These
    underdeveloped geographies are also the ones most likely to be
    medically underserved.
    ---------------------------------------------------------------------------
        \5\ The Family Physician as Economic Stimulus, http://www.graham-
    center.org/online/graham/home/tools-resources/directors-corner/dc-
    economic-stimulus.html.
    ---------------------------------------------------------------------------
        Multiple studies from the Johns Hopkins Bloomberg School of Public
    Health have demonstrated that disparities in healthcare outcomes due to
    income inequality and socioeconomic status are reduced when there is an
    adequate supply of primary care.
        AHRQ and NIH--Health Care Reform Requires New Areas of Endeavor
    Research related to the most common acute, chronic, and comorbid
    conditions that primary care clinicians care for on a daily basis is
    currently lacking. Primary care physicians are in the best position to
    design and implement research of the common clinical questions
    confronted in practice. Funding should be increased both for the
    training of primary care researchers and for this type of clinical
    research. Such training is necessary to impart critical research skills
    to the primary care workforce and to contribute to the body of
    knowledge necessary to put primary care on similar footing with other
    specialties that have established research infrastructures. We are
    pleased with the infusion of funding through the ARRA for comparative
    effectiveness research, but there is a need to provide new funding
    directly toward specific clinical and translational endeavors.
                                      ahrq
        AHRQ supports research to improve healthcare quality, reduce costs,
    advance patient safety, decrease medical errors, and broaden access to
    essential services. While targeted funding increases in recent years
    have moved AHRQ in the right direction, more core funding is needed to
    help AHRQ fulfill its mission. We support the request of the Friends of
    AHRQ which recommends an fiscal year 2010 base funding level of $405
    million, an increase of $32 million over the fiscal year 2009 level.
    This increase will preserve AHRQ's current initiatives and get the
    agency on track to a base budget of $500 million by 2013.
        IOM's report, Crossing the Quality Chasm: A New Health System for
    the 21st Century (2001) recommended a much larger investment in AHRQ.
    It recommended $1 billion a year for AHRQ to ``develop strategies,
    goals, and action plans for achieving substantial improvements in
    quality in the next 5 years.'' AHRQ is critical to retooling the
    American healthcare system.
        One of the hallmarks of the Patient-Centered Medical Home is
    evidence-based medicine. Comparative effectiveness clinical research,
    compares the impact of different options for treating a given medical
    condition, and is vital to improving the quality of healthcare. Studies
    comparing various treatments (e.g., competing drugs) or differing
    approaches (e.g., surgery vs. drug therapy) can inform clinical
    decisions by analyzing not only costs, but the relative medical
    benefits and risks for particular patient populations.
                                      nih
        Historically, the NIH has placed little emphasis on the research
    questions asked by primary care physicians and in primary care
    settings. We have been encouraged by the development of the NIH Roadmap
    and the Clinical and Translational Science Awards (CTSA), along with
    the establishment, in statute, of a funding stream that would make NIH
    more relevant to where most people receive care. We support an increase
    in NIH funding. In addition, we would like to see some report language
    that would help NIH ensure that the promise of ``bench to bedside''
    research truly becomes ``bench to bedside to community''--and community
    to bedside to bench.
        We support the inclusion of the following language in the report to
    accompany the Labor, Health and Human Services, and Education, and
    Related Agencies appropriations bills for fiscal year 2010:

        ``Translational Research has been identified by the former Director
    of the National Institutes of Health (NIH) as a road map initiative.
    The committee supports this effort and encourages NIH to integrate such
    research as a permanent component of the research portfolio of each
    institute and center. The committee urges NIH to work with the primary
    care community to determine how best to facilitate progress in
    translating existing research findings and to disseminate and integrate
    research findings into community practice. Translational research
    should also include the discovery and application of knowledge within
    the practice setting using such laboratories as practice-based research
    networks. This research spans biological systems, patients, and
    communities, and arises from questions of importance to patients and
    their physicians, particularly those practicing primary care. The
    committee requests that the Director of NIH include a progress update
    in next year's Budget Justification.''
                                   conclusion
        As the United States moves toward major healthcare reform, we urge
    the subcommittee to support programs needed to ensure the proper supply
    of primary care physicians and the type of research that will work
    together to improve healthcare outcomes, enhance equity in care, and
    lower healthcare costs. We support increases in these three important
    programs: health professions primary care medicine and dentistry
    training, AHRQ, and NIH.
                                     ______

       Prepared Statement of the State and Territorial Injury Prevention
                             Directors Association
        Thank you for the opportunity to offer written testimony to the
    Senate Appropriations Subcommittee on Labor, Health and Human Services,
    and Education and Related Agencies regarding the critical need for
    investments in State and territorial injury and violence prevention
    programs. It is well-recognized that injury and violence are a
    significant public health problem in terms of risk and costs to
    society. Injuries are the leading cause of death among persons 1-44
    years of age, and a major cause of death, disability, and
    hospitalization for all age group. There are more than 170,000 injury-
    related deaths each year in the United States and approximately 30
    million people seek emergency treatment as a result of injuries and
    violence annually.\1\ Injury is the most common cause of premature
    deaths before age 65, accounting for 30 percent of years of potential
    life lost. In 2004, 1 in 14 deaths was caused by an injury, including 3
    out of 4 deaths for adolescents and young adults.\2\
    ---------------------------------------------------------------------------
        \1\ National Center for Health Statistics. (2005). Deaths, Leading
    Causes. Center for Disease Control and Prevention. Retrieved December
    2, 2008 from http://www.cdc.gov/nchs/FASTATS/lcod.htm.
        \2\ Injury in the United States: 2007 Chartbook.. U.S. Department
    of Health and Human Services, Centers for Disease Control and
    Prevention, National Center for Health Statistics. March 2008.
    ---------------------------------------------------------------------------
        In 2000 alone, Americans suffered injuries resulting in more than
    $117 billion in medical costs and an estimated $289 billion in
    productivity losses, approximately 10 percent of total U.S. medical
    expenditures.\3\ Long-term disabilities from brain, spinal cord, and
    burn injuries, and fall-related hip fractures, frequently result in
    high costs for continued, long-term care. Additionally injuries,
    especially fractures, for persons age 65 and older make up a
    substantial proportion of Medicare expenditures. As the U.S. population
    continues to age, this problem will be an even more significant burden
    on the Medicare system.
    ---------------------------------------------------------------------------
        \3\ Zaloshnja, E., Miller, T. R., Lawrence, B. A., & Romano, E.
    (2005). The costs of unintentional home injuries. Am J Prev Med, 28:
    88-94.
    ---------------------------------------------------------------------------
        Despite the enormous toll of injury and violence, dedicated and
    ongoing Federal or State funding to respond to these problems does not
    exist as it does for other major public health priorities. State
    governments have a responsibility to protect the public's health and
    safety. A comprehensive injury and violence prevention program at the
    State health department provides focus and direction, coordinates and
    finds common ground among the many prevention partners, and makes the
    best use of limited injury and violence prevention resources. State
    public health injury and violence prevention programs apply the public
    health approach to help understand, predict and prevent injuries and
    use a population-based approach to extend the benefits of prevention
    beyond individuals.
        State and Territorial Injury Prevention Directors Association
    (STIPDA) believes that all State and territorial health departments in
    the United States must have a comprehensive injury surveillance and
    prevention programs. These programs must be adequately staffed and
    funded commensurate with the magnitude of the burden of injury and
    violence in each State. They must have programs and expertise to
    address the leading causes of unintentional and violent injuries; and
    have disaster and terrorism epidemiology and injury mitigation
    programs. State public health departments bring significant leadership
    to reduce injuries and injury-related healthcare costs by:
      --Informing the development of public policies through data and
            evaluation.
      --Designing, implementing, and evaluating injury and violence
            prevention programs in cooperation with other agencies and
            organizations.
      --Collaborating with partners in healthcare and the community.
      --Collecting and analyzing injury and violence data from a variety of
            sources to identify high-risk groups and geographic locations.
      --Providing technical support and training to injury prevention
            partners.
        State injury and violence prevention programs use surveillance data
    to determine how injuries occur, who is most at risk, and what other
    factors contribute to whether or not an individual will be injured and
    to what degree. State programs have come a long way in understanding of
    how to prevent injuries and look beyond just the personal behaviors
    that lead to an injury. They also investigate the products that people
    use, the physical and social environment, and how organizational and
    governmental policies affect the safety of our environments.
        State programs have also contributed to the dissemination of
    effective practices through partnerships with injury control research
    centers, local health departments, local coalitions and other
    organizations. To ensure the widespread adoption of these
    interventions, State programs provide training and technical assistance
    to local injury prevention efforts every day and often financial and
    in-kind support, as well as implement interventions.
        The following are some examples of how State public health
    departments have contributed to the declines we have seen in deaths due
    to injuries in this country:
      --Washington State's Injury and Violence Prevention Program has seen
            a decline in youth suicide while the U.S. rates have remained
            static. Washington found that on average 2 young people were
            dying of suicide per week with another 16 attempts that
            required hospitalization. The program estimated that a 50
            percent reduction in youth suicidal behavior would result in
            $12 million in healthcare savings alone. The program
            implemented a comprehensive prevention program including
            gatekeeper training, public awareness and strengthening
            community safety nets for youth.
      --The Georgia State Injury and Violence Prevention Program have been
            able to document at least 56 lives potentially saved through a
            unique partnership with Emergency Medical Services since 2006
            through a child safety seat education and distribution program
            for low-income families in 109 of 169 counties throughout the
            State.
      --The New York Injury and Violence Prevention Program was able to
            document reductions in bicycle-related injuries and traumatic
            brain injuries following the implementation of a statewide
            comprehensive bicycle helmet program that culminated in a
            bicycle helmet law passing easily through the State
            legislature.
      --The Oklahoma Injury Prevention Service was able to identify a high-
            risk area in Oklahoma City for house-related fire injuries. In
            response, they conducted a smoke alarm distribution program.
            After the program, Oklahoma saw an 81 percent decline in
            residential fire injury-related deaths in the target population
            while rates declined only 7 percent in the rest of Oklahoma
            during the same time period.
      --After finding that its drowning rate was ten times the national
            average, Alaska's Department of Health and Human Services
            formed a unique partnership with the U.S. Coast Guard, State
            Office of Boating Safety, Alaska Safe Kids to develop the
            ``Kids Don't Float'' program. Following extensive analysis of
            the problem, the coalition found that 90 percent of fatality
            victims were not wearing a life jacket (personal flotation
            device), more than half occurred in lakes and rivers, and that
            children younger than 18 make up a significant proportion of
            the victims. The program consists of adult and youth education
            (including peer-to-peer education for teens) and a life jacket
            loaner program. At least 5 documented lives have been saved
            through this program that is now implemented in 200 locations
            throughout the State.
      --California's Epidemiology and Prevention for Injury Control Branch-
            funded and -evaluated a statewide social marketing campaign
            designed to engage high school age males as allies in
            preventing sexual violence through a message ``My Strength is
            Not for Hurting.'' Through media efforts and ``Men of Strength
            (MOST)'' clubs in six pilot sites, California found that
            campaign appear promising, particularly when it involves MOST
            clubs, for favorably influencing high-school age males towards
            more respectful attitudes and affecting a healthier social
            climate in high schools.
        When evidence-based injury prevention strategies are implemented,
    the estimated return on investment is substantial. For instance, home
    visitation programs have been demonstrated to be particularly effective
    in reducing child abuse and injury, and provide a cost savings of
    nearly $2.88 to $5.70 per $1 spent. Other proven cost-effective injury
    prevention strategies include:

    ------------------------------------------------------------------------
                                                              Total benefits
               Intervention                 Cost per unit     to society \1\
    ------------------------------------------------------------------------
    Booster seat......................              $31/seat          $2,200
    Child bicycle helmet..............            $11/helmet            $570
    Motorcycle helmets................           $240/helmet          $4,300
    Sobriety checkpoints..............     $9,600/checkpoint         $73,000
    Midnight curfew and provisional               $74/driver            $600
     licensing for teen drivers.......
    Smoke alarm purchases.............       $33/smoke alarm            $940
    Fall prevention for high-risk              $1,250/person         $10,800
     elderly..........................
    Youth suicide prevention, native              $175/youth         $6,700
     american.........................
    ------------------------------------------------------------------------
    \1\ The total benefit to society is defined as the amount injury
      prevention interventions saved by preventing injuries, including
      medical costs, other resource costs (police, fire services, property
      damages, etc.), work loss, and quality of life costs. These benefits
      are calculated in 2004 dollars.

        Currently, the National Center for Injury Prevention and Control
    (NCIPC)provides very minimal funding to 30 States through the Public
    Health Injury Surveillance and Prevention Program (PHISPP). According
    to STIPDA's 2007 State of the States survey, States with PHISPP funding
    were more likely to have a centralized program, a full-time director,
    and greater access to key injury data sets. They were also more likely
    to provide support to local injury efforts and provide surveillance
    data and technical assistance to inform public policy related to injury
    and violence. States with PHISPP funding are well-positioned to
    leverage additional resources, implement interventions for major injury
    issues, evaluate interventions, gain political support for specific
    injury topics, and raise awareness of injury trends.
        We are asking the Senate to provide an additional $10 million to
    the NCIPC at the Centers for Disease Control and Prevention to
    supplement current investments for State injury and violence prevention
    programs. This funding would allow for:
      --Expansion and stabilization of resources for State injury and
            violence prevention programs;
      --Strengthening the ability of States to improve the collection and
            analysis of injury data, build coalitions and establish
            partnerships to promote programs and policies; and
      --Disseminating proven injury and violence prevention strategies,
            with a focus on persons at highest risk.
        Preventable injuries exact a heavy burden on Americans through
    premature deaths and disabilities, pain and suffering, healthcare
    costs, rehabilitation costs, disruption of quality of life for families
    and disruption of productive for employers. Strengthening the
    investments made to public health injury and violence prevention
    programs is a critical step to keep Americans safe and productive for
    the 21st century.
                                  about stipda
        Formed in 1992, STIPDA, is the only organization that represents
    public health injury prevention professionals in the United States.
    STIPDA has a membership of more than 300 professionals committed to
    strengthening the ability of State, territorial, and local health
    departments to reduce death and disability associated with injuries and
    violence. STIPDA engages in activities to increase awareness of injury,
    including violence, as a public health problem and works to enhance the
    capacity of public health agencies to conduct injuries and violence
    prevention.
                                     ______

     Prepared Statement of the Society for Women's Health Research and the
                       Women's Health Research Coalition
        On the behalf of the Society for Women's Health Research and the
    Women's Health Research Coalition, we are pleased to submit the
    following testimony in support of Federal funding of biomedical
    research, and in particular women's health research.
        The Society for Women's Health Research is the Nation's only
    nonprofit organization whose mission is to improve the health of all
    women through advocacy, research, and education. Founded in 1990, the
    Society brought to national attention the need for the appropriate
    inclusion of women in major medical research studies and the need for
    more information about conditions affecting women exclusively,
    disproportionately, or differently than men. The Society advocates
    increased funding for research on women's health; encourages the study
    of sex differences that may affect the prevention, diagnosis and
    treatment of disease; promotes the inclusion of women in medical
    research studies; and informs women, providers, policy makers and media
    about contemporary women's health issues. In 1999, the Women's Health
    Research Coalition was created by the Society as a grassroots advocacy
    effort consisting of scientists, researchers, and clinicians from
    across the country that are concerned and committed to improving
    women's health research.
        The Society and Coalition are committed to advancing the health of
    women through the discovery of new and useful scientific knowledge. We
    believe that sustained funding for biomedical and women's health
    research programs conducted and supported across the Federal agencies
    are absolutely essential if we are to meet the health needs of the
    population and advance the Nation's research capability.
                      national institutes of health (nih)
        Congressional investment and support for NIH continues to make the
    United States the world leader in biomedical research and has provided
    a direct and significant impact on women's health research and the
    careers of women scientists over the last decade. Great strides and
    advancements were made through the doubling of the NIH budget from
    $13.7 billion in 1998 to $27 billion in 2003, though the momentum
    driving new research in recent years was eroded under budgetary
    constraints. The 111th Congress saw the importance of increasing funds
    to NIH in the fiscal year 2009 omnibus bill providing the NIH with
    $30.317 billion, $937.5 million over fiscal year 2008, (a 3.2 percent
    increase.) Thankfully, Congress also sought fit to include the NIH in
    the American Recovery and Reinvestment Act of 2009 (Public Law 111-5)
    (ARRA) providing it with an infusion of short-term funding of $10.4
    billion. This funding will have and is having an enormous impact on
    research and research facilities throughout the United States, creating
    new jobs, new innovations and improved technologies.
        Without a robust budget, NIH has shown that it is forced to reduce
    the number of grants it is able to fund. The number of new grants
    funded by NIH has dropped steadily since fiscal year 2003 and this
    trend must stop. This shrinking pool of available grants has a
    significant impact on scientists who depend upon NIH support to cover
    their salaries and laboratory expenses to conduct high-quality
    biomedical research. Failure to obtain a grant results in reduced
    likelihood of achieving tenure. This means that new and less
    established researchers are forced to consider other careers, the end
    result being the loss of the critical workforce so desperately needed
    to sustain America's cutting edge in biomedical research.
        In order to continue the momentum of scientific advancement and
    expedite the translation of research findings from the laboratory to
    the patients who depend on these advances for improved health and
    welfare, the Society proposes a 10 percent increase more than fiscal
    year 2009, and establishing a goal of reaching an annual appropriation
    of $40 billion in the next 3 years. In addition, we request that
    Congress strongly encourage the NIH to utilize ARRA funding as well as
    appropriated dollars to assure that women's health research receives
    resources sufficient to meet the health needs of all women. Further,
    the Society recommends that NIH support the advances being discovered
    in sex-based biology research.
        Scientists have long known of the anatomical differences between
    men and women, but only within the past decade have they begun to
    uncover significant biological and physiological differences. Sex-based
    biology, the study of biological and physiological differences between
    men and women, has revolutionized the way that the scientific community
    views the sexes.
        Sex differences play an important role in disease susceptibility,
    prevalence, time of onset and severity and are evident in cancer,
    obesity, heart disease, immune dysfunction, mental health disorders,
    and many other illnesses. It is imperative that research addressing
    these important differences between males and females be supported and
    encouraged. Congress clearly recognizes these important sex differences
    and NIH should as well.
                  office of research on women's health (orwh)
        The NIH ORWH has a fundamental role in coordinating women's health
    research at NIH, advising the NIH Director on matters relating to
    research on women's health and sex and gender research; strengthening
    and enhancing research related to diseases, disorders, and conditions
    that affect women; working to ensure that women are appropriately
    represented in research studies supported by NIH; and developing
    opportunities for and support of recruitment, retention, re-entry, and
    advancement of women in biomedical careers. ORWH is currently
    implementing recommendations from the NIH working Group on Women in
    Biomedical Careers to maximize the potential of women biomedical
    scientists and engineers in both the NIH and extramural community.
        Two highly successful programs supported by ORWH that are critical
    to furthering the advancement of women's health research are Building
    Interdisciplinary Research Careers in Women's Health (BIRCWH) and
    Specialized Centers of Research on Sex and Gender Factors Affecting
    Women's Health (SCOR). These programs benefit the health of both women
    and men through sex and gender research, interdisciplinary scientific
    collaboration, and provide tremendously important support for young
    investigators in a mentored environment.
        The BIRCWH program is an innovative, trans-NIH career development
    program that provides protected research time for junior faculty by
    pairing them with senior investigators in an interdisciplinary mentored
    environment. It is expected that each scholar's BIRCWH experience will
    culminate in the development of an established independent researcher
    in women's health. The BIRCWH program has released four RFAs (1999,
    2001, 2004, and 2006). Since 2000, 335 scholars have been trained (76
    percent women) in the 24 centers resulting in more than 1,300
    publications, 750 abstracts, 200 NIH grants and 85 awards from industry
    and institutional sources. Each BIRCWH receives approximately $500,000
    a year, most of which comes from the ORWH budget but is also supported
    by many NIH Institutes and Centers.
        The SCOR program was developed by ORWH in 2002. SCORs are designed
    to increase the transfer of basic research findings into clinical
    practice by housing laboratory and clinical studies under one roof. The
    eleven SCOR programs are conducting interdisciplinary research focused
    on major medical problems affecting women and comparing gender
    differences to health and disease. Each SCOR works hard to transfer
    their basic research findings into the clinical practice setting. In
    2007, seven SCORS competed successfully for renewal and four new SCORS
    were added. In 2008, the 11 SCORs report publishing 113 journal
    articles, 144 abstracts, and 30 other publications. Each program costs
    approximately $1 million per year and results in research that would
    not have taken place without this program.
        Advancing Novel Science in Women's Health Research (ANSWHR) was
    created by ORWH in 2007 and funding starting in July 2008 to promote
    innovative new concepts and interdisciplinary research in women's
    health research and sex/gender differences. This program has had broad
    appeal and is evolving into an important scientific tool for both
    early-stage investigators and veteran researchers to test nascent
    scientific concepts relevant to women's health research and the study
    of sex and gender differences. Researchers can apply for support to
    promote innovative, interdisciplinary research to answer unresolved
    questions and expand the knowledge base in a host of areas relevant to
    women's health research. In fiscal year 2009, 13 ICs have one or more
    applications that have been scientifically reviewed and are considered
    competitive for funding. These applications, and the fiscal year 2008
    awards, represent a wide range of scientific areas as well as junior
    investigators and experienced researchers. ANSWHR serves as a way for
    interested researchers to compete for funding that is expanding the
    scientific basis for women's health research and the study of sex and
    gender differences.
        ORWH also has the Research Enhancement Awards Program (REAP) to
    support meritorious research on women's health that just missed the IC
    pay line and a Partnership with the National Library of medicine to
    identify overarching themes, specific health topics, and research
    initiatives into women's health.
        ORWH, through successful collaboration with the NIH ICs provides
    research funding for: breast cancer pharmacogenomics, HPV vaccines,
    uterine leiomyoma, vulvodynia, irritable bowel syndrome, stroke,
    substance abuse, eating disorders including obesity, menopause,
    microbicides, chronic pain syndromes, autoimmune disorders, muscular
    skeletal disorders, and health disparities among many other issues.
        Despite all of ORWH's advancements of women's health research and
    its innovative programs to advance women scientists, the office has
    seen its budget flat lined at $40.9 million for fiscal year 2008 and
    2009 after having also received a cut of $249,000 in fiscal year 2006
    and no additional funding in fiscal year 2007. Flat funding is the same
    as receiving a decrease in budget and must not continue to happen. In
    order for ORWH's programs and research grants to thrive Congress must
    direct that NIH to continue its support of ORWH and provide it with $2
    million budget increase.
                 department of health and human services (hhs)
        Under the HHS several agencies have Federal offices on women's
    health, in addition to ORWH described above. Agencies with offices,
    advisors, or coordinators for women's health or women's health research
    are HHS, the Food and Drug Administration, the Centers for Disease
    Control and Prevention, the Agency for Healthcare Quality and Research
    (AHQR), the Indian Health Service, the Substance Abuse and Mental
    Health Services Administration, the Health Resources and Services
    Administration, and the Centers for Medicare and Medicaid Services. It
    is imperative that these offices are funded at levels adequate for them
    to perform their assigned missions. We ask that the Committee Report
    clarify that Congress supports the permanent existence of these various
    Federal women's health offices and recommends that they are
    appropriately funded to ensure that their programs can continue and be
    strengthened in the coming fiscal year.
                          hhs office of women's health
        The HHS Office of Women's Health (OWH) is the Government's champion
    and focal point for women's health issues. It works to redress
    inequities in research, healthcare services, and education that have
    historically placed the health of women at risk. The OWH coordinates
    women's health efforts in HHS to eliminate disparities in health status
    and supports culturally sensitive educational programs that encourage
    women to take personal responsibility for their own health and
    wellness. OWH has a central role in communicating the appropriate
    messages to patients and healthcare providers, helping to move forward
    recent research discoveries. Without OWH's actions the task of
    translating research into practice would and will be only more
    difficult and delayed.
        Over the years OWH has been active in various efforts such as:
    joining with NIH to launch the ``The Heart Truth'' campaign, a
    prevention and awareness campaign concerning heart disease and women;
    leading a series of Women's Heart Health Fairs nationwide; partnering
    with the Lupus Foundation of America and the Advertising Council to
    launch a new lupus public awareness campaign targeted toward young
    minority women of childbearing age who are at most risk for developing
    the disease to identify early warning signs.
        OWH created a new training program ``Body Works'' for parents and
    caregivers designed to improve family eating and activity habits and is
    available in both English and Spanish. They collaborated with other
    organizations to lead a conference on ``Charting New Frontiers in Rural
    Women's Health,'' as well as hosting the third Minority Women's Health
    Summit to address the unique health issues many women of color
    experience. In addition, OWH has continued its efforts to improve the
    health of young women by providing information on their Web site to
    address eating disorders and HIV/AIDS prevention for adolescent girls,
    in conjunction with conducting their HIV/AIDS National Awareness Day.
    Further, OWH is leading efforts to improve breastfeeding information
    available to women of all cultures by offering multilingual Web sites
    and help-lines.
        This year marks the 10th anniversary of the launch of the
    womenshealth.gov Web site and care center and National Women's Health
    Week. As part of the annual celebration, OWH is sponsoring many events
    with communities, businesses and other governmental and health
    organizations to educate women on how they can improve their physical
    and mental health. Further, this year OWH is celebrating the
    publication of ``The Healthy Women'' a book with wonderful health
    information and tips for women of all ages.
        It is only through continued and increased funding that the OWH
    will be able to achieve its goals. While the budget for fiscal year
    2008 increased the OWH budget by $2 million to a total of $30 million,
    its budget was flat lined for fiscal year 2009. This is, in essence, a
    decrease due to inflation. Considering the amount and impact of women's
    health programs from OWH, we urge Congress to provide an increase of $2
    million for the HHS OWH for fiscal year 2010.
                                      ahqr
        AHQR is the lead public health service agency focused on healthcare
    quality, including coordination of all Federal quality improvement
    efforts and health services research. AHRQ's work serves as a catalyst
    for change by promoting the results of research findings and
    incorporating those findings into improvements in the delivery and
    financing of healthcare. This important information provided by AHRQ is
    brought to the attention of policymakers, healthcare providers, and
    consumers all of whom make a difference in the quality of healthcare
    women receive. Through AHRQ's research projects and findings, lives
    have been saved and underserved populations have been treated. For
    example, women treated in emergency rooms are less likely to receive
    life-saving medication for a heart attack. AHRQ funded the development
    of two software tools, now standard features on hospital
    electrocardiograph machines, which have improved diagnostic accuracy
    and dramatically increased the timely use of ``clot-dissolving''
    medications in women having heart attacks.
        While AHRQ has made great strides in women's health research, its
    budget has been dismally funded for years though targeted funding
    increases in recent years for dedicated projects are moving AHRQ in the
    right direction. However, more core funding is needed to help AHRQ
    fulfill its mission. AHRQ's budget for fiscal year 2009 was $372
    million. This must change for fiscal year 2010. The Society recognizes
    that AHRQ received a dramatic boost under ARRA of $400 million of
    dedicated stimulus funding for the comparative effectiveness project
    this amount does not add to AHRQ's base numbers. This Agency has been
    operating under a major shortfall for years. Decreased funding
    seriously jeopardizes the research and quality improvement programs
    that Congress mandates from AHRQ.
        We recommend Congress fund AHRQ at $405 million for fiscal year
    2010, an increase of $32 million more than the fiscal year 2009 level.
    This will ensure that adequate resources are available for high-
    priority research, including women's healthcare, sex and gender-based
    analyses, Medicare, and health disparities.
        In conclusion, Mr. Chairman, we thank you and this subcommittee for
    its strong record of support for medical and health services research
    and its unwavering commitment to the health of the Nation through its
    support of peer-reviewed research. We look forward to continuing to
    work with you to build a healthier future for all Americans.
                                     ______

              Prepared Statement of the Trust for America's Health
        My name is Jeff Levi, and I am Executive Director of Trust for
    America's Health (TFAH), a nonprofit, nonpartisan organization
    dedicated to saving lives by protecting the health of every community
    and working to make disease prevention a national priority. I am
    grateful for the opportunity to submit testimony to the subcommittee
    about public health appropriations.
        Americans deserve a well-financed, modern, and accountable public
    health system. Funding for public health and disease prevention is a
    down payment toward reducing healthcare costs over the long term. As
    you craft the fiscal year 2010 Labor, Health and Human Services, and
    Education, and Related Agencies appropriations bill, I hope that you
    will include robust funding for prevention and preparedness programs at
    the Centers for Disease Control and Prevention (CDC) and the Office of
    the Assistant Secretary for Preparedness and Response (ASPR) in order
    to promote health and help protect Americans from natural and manmade
    threats and disasters.
                                case for support
        There is increasing evidence that community level interventions,
    the kind of programs that CDC funding supports, make a difference in
    health outcomes and costs. In 2008, TFAH released a report, Prevention
    for a Healthier America: Investments in Disease Prevention Yield
    Significant Savings, Stronger Communities, which examines how much the
    country could save by strategically investing in community-based
    disease prevention programs. The report concludes that an investment of
    $10 per person per year in proven community-based programs to increase
    physical activity, improve nutrition, and prevent smoking and other
    tobacco use could save the country more than $16 billion annually
    within 5 years. This is a return of $5.60 for every $1 spent. The
    findings are based on a model developed by researchers at the Urban
    Institute and a review of evidence-based studies conducted by the New
    York Academy of Medicine. The evidence shows that implementing these
    programs in communities reduces rates of type 2 diabetes and high blood
    pressure by 5 percent within 2 years; reduces heart disease, kidney
    disease, and stroke by 5 percent within 5 years; and reduces some forms
    of cancer, arthritis, and chronic obstructive pulmonary disease by 2.5
    percent within 10 to 20 years, which, can save money through reduced
    health care costs to Medicare, Medicaid and private payers.
                                chronic diseases
        Chronic diseases, most of which are preventable, account for 70
    percent of deaths in the United States and approximately 75 percent of
    healthcare spending. CDC's Division of Nutrition, Physical Activity,
    and Obesity (DNPAO) provides funding to States to create, implement,
    and monitor a nutrition, physical activity, and obesity State plan. In
    the previous grant cycle, 28 grantees were supported, but CDC is only
    able to award funds to 25 States in fiscal year 2009. The Division of
    Adolescent and School Health's (DASH) Coordinated School Health Program
    assists States in improving the health of children through a program
    that engages families and communities and develops healthy school
    environments. The President's fiscal year 2010 budget proposes to
    increase funding for DASH by $5 million to fund 10 additional State
    educational agencies to assist them in meeting the needs of their K-12
    children. TFAH strongly supports this request. In the coming years, we
    will ultimately need chronic disease prevention and promotion programs
    in all 50 States. That will require $90 million for DNPAO to fund all
    approved States at the level at which they applied for funds and at
    least an additional $20 million for DASH's School Health program to
    fund all States that have been approved.
        Another important anti-obesity program is the Healthy Communities
    Program. Healthy Communities grants support communities, cities,
    States, and tribal entities to implement health promotion programs and
    community initiatives. TFAH supports at least $30 million for the
    Healthy Communities Program. Yet, funding for this program has
    decreased dramatically over recent years, from $43 million in fiscal
    year 2007 to $22.7 million in the fiscal year 2009 omnibus
    appropriations bill. We support restoration of Healthy Communities
    funding because action at the local level is essential if we are to
    begin to mitigate the obesity epidemic.
                    preparing for public health emergencies
        In December of last year, TFAH released its annual ``Ready or Not''
    report on the Nation's preparedness for a catastrophic event.
    Unfortunately, there are many areas where the United States remains
    underprepared. Funding for the Public Health Emergency Preparedness
    Cooperative Agreements to States and localities--where public health
    actually happens--has been cut in recent years. With these funds, local
    health departments have enhanced their disease surveillance systems and
    trained their staff in emergency response, including the recent H1N1
    outbreak. More than 90 percent of local health departments have
    developed mass vaccination and prophylaxis planning, conducted all-
    hazards preparedness training, and implemented new or improved
    communication systems. All States have established the infrastructure
    necessary to evaluate urgent disease reports and to activate emergency
    response operations 24 hours a day. Yet despite this progress,
    challenges remain. In its 2008 progress report, CDC noted that 31 State
    public laboratories reported difficulty recruiting qualified laboratory
    scientists, and no State public health laboratory can rapidly identify
    priority radioactive materials in clinical samples. To continue our
    commitment to emergency preparedness, sustainable funding is necessary.
    TFAH recommends $1 billion for upgrading State and local capacity, an
    increase of $253 million more than the fiscal year 2009 level. We also
    recommend $596 million for ASPR's Hospital Preparedness Program, an
    increase of $208 million over the fiscal year 2009 level, to improve
    the capacity of our hospitals and other supporting healthcare entities
    to respond to bioterrorist attacks, infectious disease epidemics, and
    other large-scale emergencies by enabling hospitals, EMS, and health
    centers to plan a coordinated response. To begin to build toward these
    funding levels, TFAH is very supportive and appreciative of the $14.5
    million increase included in the President's budget proposal for
    upgrading state and local capacity, as well as for the $32 million
    increase for the Hospital Preparedness Program.
        Another important program for our Nation's preparedness is the
    Biomedical Advanced Research and Development Authority (BARDA). BARDA
    was established in 2006 to help jumpstart innovation in vaccines,
    diagnostics, and therapeutics to combat health threats; yet limited
    funds have prevented BARDA from fulfilling its mission. BARDA provides
    incentives and guidance for research and development of products to
    counter bioterrorism and pandemic flu and manages Project BioShield,
    which includes the procurement and advanced development of medical
    countermeasures for chemical, biological, radiological, and nuclear
    agents. The fiscal year 2009 omnibus appropriations bill provided $275
    million for BARDA, an increase of approximately $173 million more than
    fiscal year 2008 levels. TFAH applauds Congress' commitment to BARDA,
    as well as the President's proposed $30 million increase, but notes
    that a significant increase in funding would be necessary to support
    the successful development of medical countermeasures. TFAH requests
    $500 million for BARDA in fiscal year 2010, with 2 years of fiscal
    availability, noting that over the next few years, higher funding
    levels must be allocated and sustained.
       bolstering the nation's ability to detect and control infectious
                      diseases such as pandemic influenza
        In fiscal year 2006, Congress appropriated $5.6 billion to the
    Department of Health and Human Services (HHS) for emergency and agency
    funding for pandemic preparedness. The funding has been used for
    stockpiling enough antiviral drugs for the treatment of more than 50
    million Americans, licensing a prepandemic influenza vaccine,
    developing rapid diagnostics and completing the sequencing of the
    entire genetic blueprints of 2,250 human and avian influenza viruses.
    The recent H1N1 influenza outbreak clearly demonstrates the importance
    of this investment.
        TFAH was pleased that the fiscal year 2009 omnibus provided $507
    million in no-year funding to be used to build vaccine production
    capacity, maintain a ready supply of eggs for the production of
    vaccine, and enable HHS to purchase medical countermeasures for its
    critical employees and contractors, as well as the Indian Health
    Service population. We are also appreciative that the House and Senate
    versions of the supplemental appropriations legislation include
    significant funding to address the H1N1 outbreak. In light of the
    challenges that could be posed if H1N1 resurfaces this fall, TFAH urges
    you to include $350 million for State and local preparedness
    activities, as proposed by the House, in the final version of the
    supplemental and to continue support for State and local preparedness
    through the annual appropriations process. Additionally, TFAH is
    hopeful that Congress will create a contingency fund to cover the
    production costs for a potential H1N1 vaccine, should health officials
    determine that mass production is necessary.
        In fiscal year 2010, we urge Congress to fully fund the President's
    request for pandemic preparedness activities, including $354 million to
    the Public Health and Social Services Emergency Fund for vaccine,
    antivirals, ventilators, and countermeasures and personal protective
    equipment for HHS clinical and patient populations, and $230 million
    for agency budgets.
                              environmental health
        An additional area of interest for TFAH is the connection between
    our environment and our health. CDC's Environmental Health Laboratory
    performs biomonitoring measurements--the direct measurement of people's
    exposure to toxic substances in the environment. By analyzing blood,
    urine, and tissues, scientists can measure actual levels of chemicals
    in people's bodies, and determine which population groups are at high
    risk for exposure and adverse health effects, assess public health
    interventions, and monitor exposure trends over time. In fiscal year
    2009, the Environmental Health Laboratory was funded at $42.7 million.
    Additional funds are needed to upgrade facilities and equipment and to
    bolster the workforce. Of the suggested $19.6 million increase, $10
    million would be used extramurally to support State public health
    laboratory biomonitoring capabilities. An additional $7.6 million would
    be used for intramural activities, including increasing the number of
    chemicals CDC measures, providing training and quality assurance for
    State laboratories; and increasing the number of studies used to assess
    health effects associated with exposure to environmental chemicals.
    Additionally, $2 million would support the National Report on
    Biochemical Indicators of Diet and Nutrition in the U.S. Population.
        TFAH is also concerned about the potential health effects of
    climate change, including injuries and fatalities related to severe
    weather events and heat waves; infectious diseases; allergic symptoms;
    respiratory and cardiovascular disease; and nutritional and water
    shortages. TFAH was appreciative of the $7.5 million included in the
    omnibus for a Climate Change Program at CDC. To expand this program,
    for fiscal year 2010, TFAH recommends $17,500,000 to enable CDC to
    bolster its climate change staff, conduct climate change research and
    begin to work with State and local health departments on capacity
    building for climate change and health preparedness. Ultimately, $50
    million is needed to develop a credible and effective Climate Change
    Program.
        Another important program, the National Environmental Health
    Tracking Network, enhances our understanding of the relationship
    between environmental exposures and the incidence and distribution of
    disease. Health tracking, through the integration of environmental and
    health outcome data, enables public health officials to better target
    preventive services so that health care providers can offer better
    care, and the public will be able to develop a clear understanding of
    what is occurring in their communities and how overall health can be
    improved. Since 2002, Congress has provided funding for pilot programs
    in some States and cities. The National Network is launching in 2009.
    With that in mind, TFAH recommends providing $50 million for CDC's
    Environmental and Health Outcome Tracking Network, an increase of $19
    million more than the fiscal year 2009 level, to expand it to
    additional States and support the continued development of a
    sustainable Network.
        Finally, TFAH supports the expansion of CDC's Global Disease
    Detection (GDD) Program. Despite remarkable breakthroughs in medical
    research and advancements in immunization and treatments, infectious
    diseases are undergoing a global resurgence that threatens health.
    Worldwide, infectious diseases are the leading killer of children and
    adolescents and are one of the leading causes of death for adults. It
    is estimated that newly emerging and re-emerging infectious diseases
    will continue to kill at least 170,000 Americans annually. CDC's GDD
    Program helps recognize infectious disease outbreaks, improve the
    ability to control and prevent outbreaks, and detect emerging microbial
    threats. To address the magnitude and urgency of emerging and resurging
    diseases, TFAH recommends $56 million for the GDD Program, an increase
    of $22 million over the fiscal year 2009 level. Funding will increase
    the number of GDD centers across the globe and bring some existing
    centers to full capacity.
        Mr. Chairman, thank you again for the opportunity to submit
    testimony on the urgent need to enhance Federal funding for public
    health programs which can save countless lives and protect our
    communities and our Nation.
                                     ______

                     Prepared Statement of the TB Coalition
                                  tuberculosis
        The TB Coalition is a network of public health, research,
    professional, and advocacy organizations working to support policies to
    eliminate tuberculosis (TB) in the United States and around the world.
    The TB Coalition is pleased to submit our recommendations for programs
    in the Labor, Health and Human Services, and Education, and Related
    Agencies Subcommittee purview. The TB Coalition, in collaboration with
    Stop TB USA, recommends a funding level of $210 million in fiscal year
    2010 for CDC's Division of TB Elimination, as authorized under the
    Comprehensive TB Elimination Act.
                                  tuberculosis
        Tuberculosis (TB) is an airborne infection caused by a bacterium,
    Mycobacterium tuberculosis. TB primarily affects the lungs but can also
    affect other parts of the body, such as the brain, kidneys or spine. TB
    is the second leading global infectious disease killer, claiming 1.8
    million lives each year. Currently, about a one-third of the world's
    population is infected with the TB bacterium. It is estimated that 9-14
    million Americans have latent TB. Tuberculosis is the leading cause of
    death for people with HIV/AIDS in the developing world. According to a
    2009 World Health Organization (WHO) report on global TB control, about
    5 percent of all new TB cases are drug resistant. The global TB
    pandemic and spread of drug resistant TB present a persistent public
    health threat to the United States.
        The major factors that have caused the spread of drug resistant
    TB--including multi-drug resistant TB (MDR) and extensively drug
    resistant (XDR) TB--are inadequate attention to and funding for basic
    TB control measures in high TB burden; resource-limited settings, which
    also have high HIV prevalence; as well as the lack of investment in new
    drugs, diagnostics and vaccines for TB. While most TB prevalent today
    is a preventable and curable disease when international prevention and
    treatment guidelines are used, many parts of the world--such as Africa
    and Eastern Europe--are struggling to implement them, giving rise to
    more drug resistant TB and increasingly, XDR-TB.
                        xdr-tb as a global health crisis
        XDR-TB has been identified in all regions of the world, including
    the United States. The strain is resistant to two main first-line drugs
    and to at least 2 of the 6 classes of second-line drugs. Because it is
    resistant to many of the drugs used to treat TB, XDR-TB treatment is
    severely limited and the strain has an extremely high-fatality rate. In
    an outbreak in the Kwazulu-Natal province of South Africa from late
    2005 through early 2006, XDR TB killed 52 out of 53 infected HIV-
    infected patients within just 3 weeks of diagnosis. According to the
    CDC, there have been 83 cases of XDR-TB in the United States between
    1998 and 2008. While the treatment success rate for XDR-TB in the
    United States is about 64 percent, the extremely high costs of treating
    XDR-TB, coupled with high fatality rates associated with the strain
    make XDR-TB a significant public health concern for the United States.
                              new tb tools needed
        Although drugs, diagnostics, and vaccines for TB exist, these
    technologies are antiquated and are increasingly inadequate for
    controlling the global epidemic. The most commonly used TB diagnostic
    in the world, sputum microscopy, is more than 100 years old and lacks
    sensitivity to detect TB in most HIV/AIDS patients and in children.
    Skin tests used in the United States are more effective at detecting
    TB, but take up to 3 days to complete. Current diagnostic tests to
    detect drug resistance take at least 1 month to complete. Faster drug
    susceptibility tests must be developed to stop the spread of drug
    resistant TB. The TB vaccine, BCG, provides some protection to
    children, but it has little or no efficacy in preventing pulmonary TB
    in adults.
        There is an urgent need for new anti-TB treatments, and
    particularly for a shorter drug regimen. Currently, the drug regime for
    TB treatment is 6-9 months. A shorter drug regimen with new classes of
    drugs active against susceptible and drug-resistant strains would
    increase compliance, prevent development of more extensive drug
    resistance, and save program costs by reducing the time required to
    directly observe therapy for patients. There is also a critical need
    for drugs that can safely be taken concurrently with antiretroviral
    therapy for HIV. The good news is that new drugs in development hold
    the promise of shortening treatment from 6-9 months to 2-4 months.
                            tb in the united states
        Although the numbers of TB cases in the United States continue to
    decline, with 12,898 new cases reported in 2008, progress towards TB
    elimination has slowed. The average annual percentage decline in the TB
    rate slowed from 7.3 percent per year during 1993-2000 to 3.8 percent
    during 2000-2008. Foreign-born and ethnic minorities bear a
    disproportionate burden of U.S. TB cases. The proportion of TB cases in
    foreign-born people has increased steadily in the last decade, from 27
    percent of all cases in 1992 to 58 percent of all cases in 2008. Border
    States and States with high immigration levels such as California,
    Texas, and New York are among the highest-burdened TB States. U.S.-born
    blacks make up almost half (45percent) of all TB cases among U.S.-born
    persons.
        In the 1970s and early 1980s, the United States began significantly
    reducing the TB control infrastructure. Consequently, the trend towards
    TB elimination was reversed and the Nation experienced an unprecedented
    resurgence of TB, including many MDR-TB cases. There was a 20 percent
    increase in cases reported between 1985 and 1992. In just one city, New
    York City, the cost to regain control of TB was more than $1 billion.
    The 2000 Institute of Medicine (IOM) report, Ending Neglect: the
    Elimination of Tuberculosis in the United States, found that the
    resurgence of TB in the United States between 1985 and 1992 was due in
    large part to funding reductions and concluded that with proper
    funding, organization of prevention and control activities, and
    research and development of new tools, TB could be eliminated as a
    public health problem in the United States.
        Drug-resistant TB poses a particular challenge to domestic TB
    control, owing to the high costs of treatment and intensive healthcare
    resources required. Treatment costs for multidrug-resistant (MDR) TB
    range from $100,000 to $300,000, which can cause a significant strain
    on State public health budgets. Inpatient care has been estimated for
    California XDR TB patients from 1993-2006 at an average of
    approximately $600,000 per patient.
                   strong state and local tb control programs
        The best defense against the development of drug-resistant
    tuberculosis is a strong network of State and local public health
    programs and laboratories. State, local, and territorial health
    departments provide important TB control services such as directly
    observed therapy (DOT, a proven method to improve adherence and thus
    prevent drug resistance), laboratory support, surveillance, contact
    tracing, and patient counseling. CDC provides about $100 million
    annually in support to State, local and territorial health departments
    to prevent and control TB.
        According to the National Tuberculosis Controller's Association,
    for every confirmed case of TB, State and local health department must
    identify and test an estimated 14 persons who may have been exposed.
    Yet after almost a decade of stagnant funding, many State TB programs
    have been left seriously under-resourced at a time when TB cases are
    growing more complex to diagnose and treat. The higher percentage of
    foreign-born TB patients adds to the need for specially trained TB
    professionals. According to a recent assessment by CDC's Division of TB
    Elimination, more than 1,077 jobs have been lost in State TB control
    programs over the last 3 years--ranging from doctors and nurses to lab
    personnel and outreach workers.
        Despite low rates, persistent challenges to TB control in the
    United States remain. Specifically: (1) racial and ethnic minorities
    continue to suffer from TB more than majority populations; (2) foreign-
    born persons are adversely impacted; (3) sporadic outbreaks/clusters
    occur, outstripping local capacity; (4) continued emergence of drug
    resistance threaten our ability to control TB; and (5) there are
    critical needs for new tools for rapid and reliable diagnosis, short,
    safe, and effective treatments, and vaccines.
                          congressional response to tb
        In recognition of the need to strengthen domestic TB control, the
    Congress passed the Comprehensive Tuberculosis Elimination Act (CTEA)
    (Public Law 110-392) in October 2008. This historic legislation was
    based on the recommendations of the Institute of Medicine and
    revitalized programs at CDC and the NIH with the goal of putting the
    United States back on the path to eliminating TB. The new law
    authorizes an urgently needed reinvestment into new TB diagnostic
    treatment and prevention tools. The TB Coalition, in collaboration with
    Stop TB USA, recommends a funding level of $210 million in fiscal year
    2010 for CDC's Division of TB Elimination, as authorized under the
    CTEA. The CTEA, as introduced, included a separate authorization of
    $100 million through CDC's TB elimination program for the development
    of urgently needed new TB diagnostic, treatment and prevention tools to
    ease the global TB pandemic. We hope that this unique area of need will
    also be considered in the final fiscal year 2010 funding levels.
                      national institutes of health (nih)
        The NIH has a prominent role to play in the elimination of
    tuberculosis through the development of new tools to fight the disease.
    However, the Coalition is concerned that the NIH has reduced funding
    for TB research from $211 million in 2007 to $160 million in 2008. We
    encourage the NIH to expand efforts, as requested under the
    Comprehensive TB Elimination Act, to develop new tools to reduce the
    rising global TB burden, including faster diagnostics that effectively
    identify TB in all populations, new drugs to shorten the treatment
    regimen for TB and combat drug resistance, and an effective vaccine.
                                   conclusion
        The global TB epidemic endangers TB control efforts in the U.S. TB
    case rates in the United States reflect the global situation. The best
    way to prevent the future development of drug-resistant strains of
    tuberculosis is through establishing and supporting effective global
    and domestic tuberculosis control programs and research programs
    through the CDC, NIH, and U.S. Agency for International Development
    (USAID). The TB Coalition appreciates this opportunity to provide
    testimony.
                                     ______

               Prepared Statement of the Tri-Council for Nursing
        The Tri-Council for Nursing, a long-standing alliance focused on
    leadership and excellence in the nursing profession, is composed of the
    American Association of Colleges of Nursing (AACN), the American Nurses
    Association, the American Organization of Nurse Executives, and the
    National League for Nursing (NLN). The collaborative leadership of
    these four professional organizations impacts the breadth of nursing
    practice, including nurse executives, educators, researchers, and
    nurses providing direct patient care. The Tri-Council asks the
    subcommittee to provide $263.4 million in fiscal year 2010 for the
    Nursing Workforce Development Programs under title VIII of the Public
    Health Service Act, administered by the Health Resources and Services
    Administration (HRSA).
        In light of the economic challenges facing our country today, the
    Tri-Council urges the subcommittee to focus on the larger context of
    building the capacity needed to meet the increasing healthcare demands
    of our Nation's population. Such public policy will require sustained
    investments aimed at refocusing the current healthcare system toward
    promoting health, while simultaneously improving value for our dollars.
    The title VIII Nursing Workforce Development Programs are proven policy
    instruments that help assure an adequately prepared nursing workforce.
    These programs--
      --Increase access to healthcare in underserved areas through improved
            composition, diversity, and retention of the nursing workforce;
      --Advance quality care by strengthening nursing education and
            practice; and
      --Develop the identification and use of data, program performance
            measures, and outcomes to make informed decisions on nursing
            workforce matters.
        The Tri-Council applauds the subcommittee for the emergency
    supplement provided across all the health professions programs via the
    American Recovery and Reinvestment Act (Public Law 111-5). We also
    value the enacted fiscal year 2009 Omnibus Appropriations bill (Public
    Law 111-8) providing $171.031 million specifically for the title VIII
    Nursing Workforce Development Programs. These investments are a
    critical component supporting our healthcare infrastructure.
        Examining the broad context, the healthcare industry remains the
    largest industrial complex in the United States. Studies of the
    Nation's gross domestic product (GDP) show healthcare spending
    achieving a relatively high rate of real growth, with the portion of
    GDP devoted to healthcare growing from 8.8 percent in 1980 to 16.2
    percent of GDP in 2007. While healthcare spending demands greater
    efficiencies, it also has helped to sustain our Nation's sagging
    economy.
        Since 2001, healthcare is virtually the only sector that added jobs
    to the economy on a net basis. In March 2009, the U.S. Bureau of Labor
    Statistics (BLS) reported continued growth in the healthcare sector,
    despite our economy's freefall in a down cycle with unemployment
    reaching 8.1 percent in February 2009. With that month's job loss of
    681,000 realized in nearly all major industries, BLS also reported the
    addition of 27,000 new jobs at hospitals, long-term care facilities,
    and other ambulatory care settings.
        As the predominant occupation in the healthcare industry, the nurse
    workforce likely is filling most of the noted job openings. Nurses are
    the front line of healthcare delivery throughout the Nation, and the
    BLS numbers support that description showing the nurse workforce at
    well more than four times the size of the medical workforce. Increased
    fiscal year 2010 investments in title VIII will help counterbalance the
    economic meltdown threatening nursing programs operating in
    congressional districts and serving communities by supporting nursing
    education--providing title VIII loans, scholarships, traineeships, and
    programmatic funding.
                  nursing shortage outpaces capacity building
        The Tri-Council contends that an episodic increased funding of
    title VIII will not fully fill the gap generated by an 11-year nursing
    shortage felt throughout the entire U.S. health system and projected to
    continue. The BLS projections estimate that RNs will have the greatest
    growth rate of all U.S. occupations in the period spanning 2006-2016,
    with more than 1 million new and replacement nurses needed by 2016.
    Despite this projected expansion in the profession, numerous other
    studies anticipate a growing national nurse workforce shortage to
    intensify as the baby boomer cohort ages, the current nurse workforce
    retires, and the demand for healthcare accrues.
        Funding levels for the HRSA title VIII Nursing Workforce Programs
    are failing to support the numerous qualified applicants seeking
    assistance from these programs. In the last 3 years, virtually flat
    title VIII funding, along with inflation and increased educational and
    administrative costs, has decreased purchasing power. According to HRSA
    statistics, in fiscal year 2006 the title VIII programs directly or
    indirectly supported 91,189 nurses and nursing students. In fiscal year
    2007, the number of grantees dropped by 21 percent and in 2008 the
    grantees dropped by 28 percent to support only 51,657 nurses and
    nursing students.
        Additionally, schools of nursing continue to suffer from a growing
    shortage of faculty, a troubling infrastructure trend that exacerbates
    the nurse workforce demand-supply gap. According to a study conducted
    by the AACN in 2008, schools of nursing turned away 49,948 qualified
    applicants to baccalaureate and graduate nursing programs. The top
    reasons cited for not accepting these potential students was a lack of
    qualified nurse faculty and resource constraints. Without faculty,
    nursing education programs are prevented from admitting many qualified
    students who are applying to their programs. (Data are Internet
    accessible at http://www.aacn.nche.edu/Media/NewsReleases/2009/
    workforcedata.html.)
        The AACN survey results are reinforced by the NLN study of all
    types of prelicensure RN programs, which prepare students to sit for
    the RN licensing exam (i.e., baccalaureate, associate, and diploma
    degree). The NLN statistics indicate more than 1,900 unfilled full-time
    faculty positions existed nationwide in 2007, affecting more than one-
    third (36 percent) of all schools of nursing. Significant recruitment
    challenges were found with 84 percent of nursing schools at-tempting to
    hire new faculty in 2007-2008, more than three-quarters (79 percent)
    reporting recruitment as ``difficult'' and almost 1 in 3 schools found
    it ``very difficult.'' The two main difficulties cited were ``not
    enough qualified candidates'' (cited by 46 percent of schools),
    followed by inability to offer competitive salaries--cited by 38
    percent. (Data are Internet accessible at www.nln.org/research/slides/
    index.htm.)
                              the funding reality
        If the United States is to reverse the eroding trends in the nurse
    and nurse faculty workforce, the Nation must make a significant
    investment in the title VIII programs, which are charged to favor
    institutions educating nurses for practice in rural and medically
    underserved communities. At adequate funding levels the title VIII
    programs supporting the education of registered nurses, advanced
    practice registered nurses, nurse faculty, and nurse researchers have
    demonstrated successful intervention strategies to solving past nursing
    shortages.
        A brief examination of the HRSA title VIII illustrates the robust
    nature of these programs:
        Section 811.--The Advanced Education Nursing (AEN) Program funds
    traineeships for individuals preparing to be nurse practitioners, nurse
    midwives, nurse administrators, public health nurses, and nurse
    educators, among other graduate-level education nursing roles. The AEN
    awards assisted nurse education programs to support 3,419 graduate
    nursing students in fiscal year 2008.
        Section 821.--The Nursing Workforce Diversity Program funds grants
    and contracts to schools of nursing, nurse-managed health centers
    (NMCs), academic health centers, State and local governments, and
    nonprofit entities to increase nursing education opportunities for
    individuals from disadvantaged backgrounds and under-represented
    populations among RNs. This program--of proven intervention
    strategies--supported 18,741 students in fiscal year 2008, seeking to
    ensure a culturally diverse workforce to provide healthcare for a
    culturally diverse patient population.
        Section 831.--The Nurse Education, Practice and Retention Program
    provides support for academic and continuing education projects
    designed to strengthen the nursing workforce. Several of this program's
    priorities apply to quality patient care including developing cultural
    competencies among nurses and providing direct support to establishing
    or expanding NMCs in noninstitutional settings to improve access to
    primary healthcare in medically underserved communities. The program
    also provides grants to improve retention of nurses and enhanced
    patient care. In fiscal year 2008, approximately 6,000 nurses and
    nursing students were supported.
        Section 846.--The Nurse Loan Repayment and Scholarship Programs is
    divided into two primary elements. The Nursing Education Loan Repayment
    Program (NELRP) assists individual RNs by re-paying up to 85 percent of
    their qualified educational loans over 3 years in return for their
    commitment to work at health facilities with a critical shortage of
    nurses, such as departments of public health, community health centers,
    and disproportionate share hospitals. In fiscal year 2008, of the 5,875
    applications reviewed by HRSA, only 435 students (7.4 percent) received
    NELRP awards. Similarly, the Nurse Scholarship Program (NSP) provides
    financial aid to individual nursing students in return for working a
    minimum of 2 years in a healthcare facility with a critical nursing
    shortage. In fiscal year 2008, NSP turned away most of the applicants
    owing to a lack of adequate funding, resulting in the distribution of
    only 169 student awards.
        Section 846A.--The Nurse Faculty Loan Program (NFLP) supports the
    establishment and operation of a loan fund within participating schools
    of nursing to assist RNs to complete their education to become nursing
    faculty. The NFLP grants provide a cancellation provision in which 85
    percent of the loan, plus interest, may be cancelled over 4 years in
    return for serving as full-time faculty in a school of nursing. NFLP
    granted 729 awards in fiscal year 2008.
        Section 855.--The Comprehensive Geriatric Education Grant Program
    focuses on training, curriculum development, faculty development, and
    continuing education for nursing personnel caring for the elderly. In
    fiscal year 2008, 18 awards were made in this program.
        While title VIII is the largest source of Federal funding for
    nursing, the current level of investment falls short of remedying a
    chronic underfunding of the Nursing Workforce Development Programs,
    compared to the existing and imminent shortages these programs address.
    The title VIII authorities are capable of providing flexible and
    effective support to assist students, schools of nursing, and health
    systems in their efforts to recruit, educate, and retain registered
    nurses. Recent efforts have shown that aggressive and innovative
    strategies can help avert the nurse and nurse faculty shortages. The
    Tri-Council for Nursing understands the competing priorities faced by
    this Congress, but we also maintain that title VIII Nursing Workforce
    Development Programs must be funded at an adequate level to begin to
    impact the shortage and to address the complex health needs of the
    Nation. The contributions of nurses in our healthcare system are
    multifaceted, and are impacted directly by the level of Federal funding
    that supports nursing programs.
                                     ______

                  Prepared Statement of The Endocrine Society
        The Endocrine Society is pleased to submit the following testimony
    regarding fiscal year 2010 Federal appropriations for biomedical
    research, with an emphasis on appropriations for the National
    Institutes of Health (NIH). The Endocrine Society is the world's
    largest and most active professional organization of endocrinologists
    representing more than 14,000 members worldwide. Our organization is
    dedicated to promoting excellence in research, education, and clinical
    practice in the field of endocrinology. The Society's membership
    includes thousands of researchers who depend on Federal support for
    their careers and their scientific advances.
        Since the doubling of its budget, the NIH has received annual
    funding increases below the rate of biomedical inflation. Fiscal year
    2009 appropriations resulted in the first real-dollar increase in NIH
    funding since fiscal year 2003. This decline in useable dollars has
    resulted in a significant decrease in the number of R01 grants funded.
    In 2003, the number of new and continuing R01s was 7,211; the number of
    grants awarded in 2008 dropped to 5,886. As a result of the decreasing
    number of grants awarded, the success rate for new R01 grants dropped
    from 25.5 percent in 1999 to a low of 16.3 percent in 2006 (the 2008
    success rate was 19 percent). Not only does the decline in grants
    affect the number of scientists who are able to continue their research
    and discover new treatments and cures, it also has a significant impact
    on the U.S. economy.
        In fiscal year 2007, every $1 million that the public invested in
    NIH research generated $2.21 million in new business activity across
    the Nation. At a recent House Energy and Commerce Committee hearing,
    Dr. Raynard Kington, Acting Director of the NIH, stated that each NIH
    grant supports seven jobs on average. Since grants are dispersed to all
    50 States and 90 percent of Congressional Districts, increasing funding
    for science will have a significant positive impact on job growth. And
    unlike many other proposals to stimulate the economy, funding NIH
    grants can have an immediate impact on the economy because these grants
    can be funded in a matter of weeks, stimulating local economies through
    salaries and purchase of equipment, laboratory supplies, and vendor
    services.
        Members of Congress and President Obama recognized the positive
    impact that funding NIH research can have on the economy and allocated
    more than $10 billion to the NIH in the American Recovery and
    Reinvestment Act of 2009. These funds will go a long way towards
    increasing the success rate of new R01 applications, keeping scientists
    employed, and creating new jobs. The Endocrine Society thanks Congress
    for the support of biomedical research funding in the ARRA.
        However, the Federal Government needs to make a long-term,
    sustainable commitment to biomedical research funding. The money
    allocated to the NIH in the ARRA is a one-time infusion of money, and
    it is unclear how much NIH's budget will be when the stimulus funds run
    out at the end of fiscal year 2010. These funds will create thousands
    of new jobs, most of which will end when fiscal year 2011 begins if
    Congress does not bring NIH's budget closer to $40 billion than to $30
    billion. The loss of these jobs could have a drastic effect on our
    economy and counteract the benefits realized during fiscal year 2009
    and 2010 as a result of the stimulus funding.
        While the Nation is struggling with a failing economy, health
    reform is also on the top of the minds of Members of Congress and the
    American people. With the aging of the Baby Boomer generation, the
    incidence of costly, chronic conditions will significantly increase,
    and a large portion of the projected increase in healthcare costs will
    be as a result of escalating costs associated with diabetes, obesity,
    hypertension, Alzheimer's disease, muscular dystrophy, cystic fibrosis,
    and stroke. In order to prevent and treat these diseases, and save the
    country billions in healthcare costs, significant investment in
    biomedical research will be needed. For instance, treatments that delay
    or prevent diabetic retinopathy save the country $1.6 billion a year,
    and new treatments that delay the onset and progression of Alzheimer's
    disease by 5 years can save $50 billion a year in healthcare costs.
        The Endocrine Society remains deeply concerned about the future of
    biomedical research in the United States without sustained support from
    the Federal Government. The Society strongly supports the continued
    increase in Federal funding for biomedical research in order to provide
    the additional resources needed to enable American scientists to
    address the burgeoning scientific opportunities and new health
    challenges that continue to confront us. The Endocrine Society supports
    President Obama's campaign pledge to double the NIH budget over 10
    years. We therefore recommend that NIH receive an increase of at least
    7 percent in fiscal year 2010 to prepare for the poststimulus era and
    ensure the steady, sustainable growth necessary to complete the
    President's vision of doubling the investment in basic and clinical
    research.
                                     ______

             Prepared Statement of The Mended Hearts, Incorporated
        I am Robert A. Scott, National Advocacy Chairman for The Mended
    Hearts, Incorporated, a heart disease support group with more than 300
    chapters across the United States and Canada. In 2008, accredited
    Mended Hearts volunteers visited about 3,000 heart patients in more
    than 400 hospitals throughout the United States.
        As a walking testimony of the benefits of the National Institutes
    of Health (NIH)-supported heart research, I would like to share my
    story. In 1998, at age 48, I suffered my first heart attack while
    playing volleyball. While at Woonsocket, Rhode Island's Landmark
    Medical Center, doctors diagnosed me as suffering a so-called silent
    heart attack. I learned that as many as 4 million Americans experience
    this type of episode--a heart attack with no warning.
        After being stabilized, I was transferred to Roger Williams
    Hospital, in Providence, Rhode Island for a heart catheterization--the
    gold standard for diagnosis of heart problems. The procedure showed
    that I had a blockage in my artery that required a stent to open it.
    Also, it showed that the lower chamber of my heart was damaged,
    resulting in congestive heart failure that could be controlled with
    medicine. A stent was inserted in my artery in Rhode Island Hospital.
        In 1999, I received another heart catheterization in Miriam
    Hospital because of the damage to my heart from the silent heart
    attack. However, this time, I was told that my artery could not be
    repaired with a stent and that I needed heart bypass surgery the next
    morning. Calling me a high-risk patient because of my age and my
    weakened heart, my surgeon encouraged me to find a doctor in Boston
    because my heart might not start again. However, he assured me that if
    this happens they had a device that could keep me alive for only 7
    hours. Thank goodness, he told me that in Boston they had another
    device that could keep me alive for 7 months while they located a
    replacement heart. In less then 10 hours, I went from the possibility
    of needing another stent, heart bypass surgery, and a heart transplant.
    My journey with heart disease continued.
        My next stop was to visit my local cardiologist in Woonsocket who
    estimated my survival rate at 20 percent, but he thought I would
    survive the heart bypass surgery. Thankfully, he was right and I
    survived heart bypass surgery.
        But my journey didn't end there. My congestive heart failure was
    causing my heart to beat irregularly, so an implantable defibrillator
    was inserted to control the problem in 2002. However, this device had
    to be replaced nearly 4 years later. My story continues in 2007 where I
    started experiencing daily chest pain and shortness of breath. Yet
    another heart catheterization showed that I needed an additional stent,
    but this time in Miriam Hospital. After the procedure, the doctor told
    me the original heart bypass surgery was no longer effective. Although
    I was scared, my doctors comforted me by explaining that a new medical
    innovation could save my life-a drug eluting stent. They explained that
    it could open up the original blockage from my silent heart attack. My
    doctor explained that if these state-of-the art stents had been
    available in 1998, I would not have had to have heart bypass surgery.
        Today, heart attack, stroke, and other cardiovascular diseases
    remain our Nation's most costly and No. 1 killer and a major cause of
    disability. Thanks to medical research supported by the NIH, I am alive
    today. I am concerned that NIH continues to invest only 4 percent of
    its budget on heart research and a mere 1 percent on stroke research
    when there are so many people in our country just like I am. Enhanced
    NIH funding dedicated to heart and stroke research will bring us closer
    to a cure for these often deadly and disabling diseases.
                                     ______

           Prepared Statement of the United Tribes Technical College
        For 40 years, United Tribes Technical College (UTTC) has provided
    postsecondary career and technical education, job training, and family
    services to some of the most impoverished Indian students from
    throughout the Nation. We are governed by the five tribes located
    wholly or in part in North Dakota. We have consistently had excellent
    results, placing Indian people in good jobs and reducing welfare rolls.
    The Perkins funds constitute about half of our operating budget and
    provide for our core instructional programs for many of our Associate
    of Applied Science degrees. We do not have a tax base or State-
    appropriated funds on which to rely.
        The request of the UTTC Board is for the following authorized
    programs:
      --$8.5 million or $727,000 above the fiscal year 2009 enacted level
            for section 117 of the Carl Perkins Act. These funds are shared
            via a formula by UTTC and Navajo Technical College.
      --Provision of additional funding for title III and title III-A of
            the Higher Education Act (HEA) that provide construction funds
            for facilities at institutions of higher education (title III)
            and at tribally controlled colleges (title III-A). For example,
            UTTC needs an additional $10.9 million to complete the
            construction of a new science and technology building towards
            which UTTC already has obtained $3 million.
        The students who attend UTTC are from Indian reservations from
    throughout the Nation, with a significant portion of them being from
    the Great Plains area. Our students come from impoverished backgrounds
    or broken families. They may be overcoming extremely difficult personal
    circumstances as single parents. They often lack the resources, both
    culturally and financially, to go to other mainstream institutions.
    Through a variety of sources, including funds from section 117 of the
    Carl Perkins Act, UTTC provides a set of family and culturally based
    campus services, including: an elementary school for the children of
    students, housing, day care, a health clinic, a wellness center,
    several on-campus job programs, student government, counseling,
    services relating to drug and alcohol abuse and job placement programs.
    The Carl Perkins funds we receive are essential to our students'
    success.
        Perkins Authorization.--Section 117 of the Carl D. Perkins Career
    and Technical Education Act (20 U.S.C. section 2327) is the source of
    authorization of Perkins funding for UTTC. Section 117 is entitled
    ``Tribally Controlled Postsecondary Career and Technical
    Institutions.'' First authorized in 1991, Congress has continued this
    authorization in the subsequent reauthorizations of the Perkins Act.
    Funding under this act has in recent years been distributed on a
    formula basis to UTTC and to Navajo Technical College.
        Despite the explicit congressional authorization for Carl Perkins
    funding for section 117, and despite the administration's requests for
    funding for section 117 in all previous years, the Bush administration
    requested nothing for this program for fiscal year 2009. We are pleased
    that Congress recognized the value of UTTC's programs, and instead gave
    a priority to UTTC and Navajo Technical College by appropriating a
    $227,000 increase for section 117 Perkins in the recently enacted
    Omnibus appropriations bill for fiscal year 2009. However, in the
    process our section 117 program was listed as an earmark, despite the
    authorization for the appropriated amount. As a continuing, authorized
    Native American serving program, we should not be considered an
    earmark.
        UTTC Performance Indicators.--UTTC has:
      --An 80 percent retention rate.
      --A placement rate of 94 percent (job placement and going on to 4-
            year institutions).
      --A projected return on Federal investment of 20 to 1 (2005 study
            comparing the projected earnings generated over a 28-year
            period of UTTC associate of applied science and bachelor degree
            graduates of June 2005 with the cost of educating them).
      --The highest level of accreditation. The North Central Association
            of Colleges and Schools has accredited UTTC again in 2001 for
            the longest period of time allowable--10 years or until 2011--
            and with no stipulations. We are also 1 of only 2 tribal
            colleges accredited to offer accredited on-line (Internet-
            based) associate degrees.
      --More than 20 percent of our graduates go on to 4-year or advanced
            degree institutions.
        We also note the January 13, 2009, report of the Department of
    Education's Office of Vocational and Adult Education on its recent site
    visit to UTTC (October 7-9, 2008). While some suggestions for
    improvements were made, the Department commended UTTC in many areas:
    for efforts to improve student retention; the commitment to data-driven
    decisionmaking, including the implementation of the Jenzabar system
    throughout the institution; the breadth of course offerings;
    collaboration with 4-year institutions; expansion of online degree
    programs; unqualified opinions on both financial statements and
    compliance in all major programs; being qualified as a low-risk
    grantee; having no reportable conditions and no known questioned costs;
    clean audits; and use of the proposed measurement definitions in
    establishing institutional performance goals.
        The demand for our services is growing and we are serving more
    students. For the 2008-2009 year we enrolled 1,023 students (an
    unduplicated count), nearly four times the number served just 6 years
    ago. Most of our students are from the Great Plains, where the Indian
    reservations have a jobless rate of 76 percent (Source: 2003 BIA Labor
    Force Report), along with increasing populations. These statistics
    dramatically demonstrate the need for our services at increased levels
    for at least the next 10 years.
        In addition, we are serving 141 students during school year 2008-
    2009 in our Theodore Jamerson Elementary school and 202 children, birth
    to 5, are being served in our child development centers.
        UTTC course offerings and partnerships with other educational
    institutions. We offer 17 accredited vocational/technical programs that
    lead to 17, 2-year degrees (Associate of Applied Science (AAS)) and 11,
    1-year certificates, as well as a 4-year degree in elementary education
    in cooperation with Sinte Gleska University in South Dakota.
        Licensed Practical Nursing.--This program has one of the highest
    enrollments at UTTC and results in the greatest demand for our
    graduates. Our students have the ability to transfer their UTTC credits
    to the North Dakota higher educational system to pursue a 4-year
    nursing degree.
        Medical Transcription and Coding Certificate Program.--This program
    provides training in transcribing medical records into properly coded
    digital documents. It is offered through the college's Exact Med
    Training program and is supported by Department of Labor funds.
        Tribal Environmental Science.--Our Tribal Environmental Science
    program is supported by a National Science Foundation Tribal College
    and Universities Program grant. This 5-year project allows students to
    obtain a 2-year AAS degree in Tribal Environmental Science.
        Community Health/Injury Prevention/Public Health.--Through our
    Community Health/Injury Prevention Program we are addressing the injury
    death rate among Indians, which is 2.8 times that of the U.S.
    population, the leading cause of death among Native Americans ages 1-
    44, and the third leading cause of death overall. This program has in
    the past been supported by the Indian Health Service, and is the only
    degree-granting Injury Prevention program in the Nation. Given the
    overwhelming health needs of Native Americans, we continue to seek new
    resources to increase training opportunities for public health
    professionals.
        Online Education.--Our online education courses provide increased
    opportunities for education by providing web-based courses to American
    Indians at remote sites as well as to students on our campus. These
    courses provide needed scheduling flexibility, especially for students
    with young children. They allow students to access quality, tribally
    focused education without leaving home or present employment. However,
    we also note the lack of on-line opportunities for Native Americans in
    both urban and rural settings, and encourage the Congress to devote
    more resources in this area.
        We offer online fully accredited degree programs in the areas of
    Early Childhood Education, Community Health/Injury Prevention, Health
    Information Technology, Nutrition and Food Service and Elementary
    Education. More than 80 courses are currently offered online, including
    those in the Medical Transcription and Coding program. We presently
    have 50 online students in various courses and 137 online students in
    the Medical Transcription program.
        We also provide an online Indian Country Environmental Hazard
    Assessment program, offered through the Environmental Protection
    Agency. This is a training course designed to help tribes understand
    how to mitigate environmental hazards in reservation communities.
        Computer Information Technology.--This program is at maximum
    student capacity because of limitations on resources for computer
    instruction. In order to keep up with student demand and the latest
    technology, we need more classrooms, equipment and instructors. We
    provide all of the Microsoft Systems certifications that translate into
    higher income earning potential for graduates.
        Nutrition and Food Services.--UTTC helps meet the challenge of
    fighting diabetes and other health problems in Indian Country, such as
    cancer, through education and research. Indians and Alaska natives have
    a disproportionately high rate of type 2 diabetes, and have a diabetes
    mortality rate that is three times higher than the general U.S.
    population. The increase in diabetes among Indians and Alaska natives
    is most prevalent among young adults aged 25-34, with a 160 percent
    increase from 1990-2004. (Source: Fiscal Year 2009 Indian Health
    Service Budget Justification). Our research about native foods is
    helping us learn how to reduce the high levels of diseases in our
    communities.
        As a 1994 Tribal Land Grant institution, we offer a Nutrition and
    Food Services AAS degree in order to increase the number of Indians
    with expertise in nutrition and dietetics. Currently, there are very
    few Indian professionals in the country with training in these areas.
    Our degree places a strong emphasis on diabetes education, traditional
    food preparation, and food safety. We have also established the United
    Tribes Diabetes Education Center that assists local tribal communities,
    our students and staff to decrease the prevalence of diabetes by
    providing educational programs, training and materials. We publish and
    make available tribal food guides to our on-campus community and to
    tribes.
        Business Management/Tribal Management.--Another critical program
    for Indian country is business and tribal management. This program is
    designed to help tribal leaders be more effective administrators and
    entrepreneurs. As with all our programs, curriculum is constantly being
    updated.
        Job Training and Economic Development.--UTTC continues to provide
    economic development opportunities for many tribes. We are a designated
    Minority Business Development Center serving South and North Dakota. We
    administer a Workforce Investment Act program and an internship program
    with private employers in the region.
        South Campus Development.--The bulk of our current educational
    training and student housing is provided in 100-year-old buildings,
    part of a former military base used by UTTC since its founding in 1969
    and donated to us by the United States in 1973. They are expensive to
    maintain, do not meet modern construction and electrical code
    requirements, are mostly not ADA compliant, and cannot be retrofitted
    to be energy efficient.
        As a result, UTTC has developed plans for serving more students in
    new facilities that will provide training and services to meet future
    needs. We are now developing land purchased with a donation that will
    become our south campus. Infrastructure for one-fourth of the new
    campus has been completed, and we have now obtained partial funds for a
    new, and badly needed, science, math, and technology building. We need
    an additional $10.9 million to help complete this building. Our vision
    for the south campus is to serve up to 5,000 students. We expect that
    funding for the project will come from Federal, State, tribal, and
    private sources. Without additional funding for titles III and III-A of
    the HEA, that provide construction funds for campuses such as ours,
    many students will be denied the opportunity for higher education.
        Our Department of Education funds are essential to the operation of
    our campus. Our programs at UTTC continue to be critical and relevant
    to the welfare of Indian people throughout the Great Plains region and
    beyond. Thank you for your consideration of our request.

           LIST OF WITNESSES, COMMUNICATIONS, AND PREPARED STATEMENTS

                                  ----------
                                                                       Page

    Advocate Health Care, Prepared Statement of the..................   296
    Ad Hoc Group for Medical Research, Prepared Statement of the.....   298
    AIDS:
        Action, Prepared Statement of the............................   237
        Institute, Prepared Statement of the.........................   299
    Alexander, Senator Lamar, U.S. Senator From Tennessee, Questions
      Submitted by...................................................   234
    Alliance for Aging Research, Prepared Statement of the...........   278
    Alving, Dr. Barbara M., Director, National Center for Research
      Resources, National Institutes of Health, Department of Health
      and Human Services, Prepared Statement of......................    86
    Alzheimer's Association, Prepared Statement of the...............   240
    America's Promise Alliance, Prepared Statement of the............   319
    American:
        Academy of:
            Family Physicians, Prepared Statement of the.............   261
            Opthamology, Prepared Statement of the...................   272
            Physician Assistants, Prepared Statement of the..........   275
        Association:
            for:
                Cancer Research, Prepared Statement of the...........   254
                Dental Research, Prepared Statement of the...........   259
                Geriatric Psychiatry, Prepared Statement of the......   263
            Of:
                Colleges:
                    Of:
                        Nursing, Prepared Statement of the...........   246
                        Osteopathic Medicine, Prepared Statement of
                      the............................................   250
                        Pharmacy, Prepared Statement of the..........   251
                        Immunologists, Prepared Statement of the.....   266
                    For Teacher Education, Letter From the...........   257
                Nurse Anesthetists, Prepared Statement of the........   270
        College of:
            Obstetricians and Gynecologists, Prepared Statement of
              the....................................................   279
            Physicians, Prepared Statement of the....................   282
            Preventive Medicine, Prepared Statements of the........284, 287
        Heart Association, Prepared Statement of the.................   293
        Indian Higher Education Consortium, Prepared Statement of the   302
        National Red Cross, Prepared Statement of the................   311
        Nurses Association, Prepared Statement of the................   309
        Physiological:
            Association, Prepared Statement of the...................   322
            Society, Prepared Statement of the.......................   329
        Public Power Association, Prepared Statement of the..........   325
        Society:
            For:
                Microbiology, Prepared Statements of the...........334, 337
                Nutrition, Prepared Statement of the.................   340
                Pharmacology and Experimental Therapeutics, Prepared
                  Statement of the...................................   344
            Of:
                Plant Biologists, Prepared Statement of the..........   342
                Tropical Medicine and Hygiene, Prepared Statement of
                  the................................................   346
        Thoracic Society, Prepared Statement of the..................   349
    Americans for Nursing Shortage:
        Alliance, Prepared Statement of the..........................   314
        Relief Alliance, Prepared Statement of the...................   317
    Animal Welfare Institute, Prepared Statement of the..............   354
    Association:
        For:
            Clinical Research Training, Prepared Statement of the....   289
            Psychological Science, Prepared Statement of the.........   326
            Research in Vision and Ophthalmology, Prepared Statement
              of the.................................................   332
        Of:
            American Cancer Institutes, Prepared Statement of the....   243
            Independent Research Institutes, Prepared Statement of
              the....................................................   305
            Maternal and Child Health Programs, Prepared Statement of
              the....................................................   306
            Rehabilitation Nurses, Prepared Statement of the.........   330
            Women's Health, Obstetric and Neonatal Nurses, Prepared
              Statement of the.......................................   352

    Battey, Dr. James F., Jr., Director, National Institute on
      Deafness and Other Communication Disorders, National Institutes
      of Health, Department of Health and Human Services, Prepared
      Statement of...................................................   104
    Berg, Dr. Jeremy M., Director, National Institute of General
      Medical Sciences, National Institutes of Health, Department of
      Health and Human Services, Prepared Statement of...............   113
    Big Brothers Big Sisters of America, Prepared Statement of the...   356
    Birnbaum, Dr. Linda, Director, National Institute of
      Environmental Health Sciences, National Institutes of Health,
      Department of Health and Human Services, Prepared Statement of.   111
    Brain Injury Association of America, Letter From the.............   358
    Briggs, Dr. Josephine P., Director, National Center for
      Complementary and Alternative Medicine, National Institutes of
      Health, Department of Health and Human Services, Prepared
      Statement of...................................................    84

    Center for Global Health Policy, Prepared Statement of the.......   368
    Central Technical Services, Prepared Statement of the............   380
    Children's Environmental Health Network, Prepared Statement of
      the............................................................   362
    Children and Adults with Attention-Deficit/Hyperactivity Disorder
      (CHADD), Prepared Statement of the.............................   372
    Close Up Foundation, Prepared Statement of the...................   383
    Coalition:
        For Health Services Research, Prepared Statement of the......   374
        Of Northeastern Governors, Prepared Statement of the.........   377
    Cochran, Senator Thad, U.S. Senator From Mississippi:
        Opening Statement of.........................................     1
        Questions Submitted by.....................................160, 275
        Statements of................................................3, 164
    Council on Social Work Education, Prepared Statement of the......   378
    Crohn's and Colitis Foundation of America, Prepared Statement of
      the............................................................   360
    Cystic Fibrosis Foundation, Prepared Statement of the............   365

    Digestive Disease National Coalition, Letter From the............   385
    Duncan, Hon. Arne, Secretary, Office of the Secretary, Department
      of Education...................................................   163
        Prepared Statement...........................................   173
        Summary Statement of.........................................   167
    Durbin, Richard J., U.S. Senator From Illinois, Questions
      Submitted by...................................................    61
    Dystonia Medical Research Foundation, Prepared Statement of the..   386

    Endocrine Society, Prepared Statement of the.....................   551

    Fauci, Anthony S., M.D., Director, National Institute of Allergy
      and Infectious Diseases, National Institutes of Health,
      Department of Health and Human Services........................    63
        Prepared Statement of........................................    79
    Family Violence Prevention Fund, Prepared Statement of the.......   398
    Federation of American Societies for Experimental Biology,
      Prepared Statement of the......................................   388
    Friends of the Health Resources and Services Administration,
      Prepared Statement of the......................................   390
    FSH Society, Inc., Prepared Statement of the.....................   395

    Glass, Dr. Roger I., Director, Fogarty International Center,
      National Institutes of Health, Department of Health and Human
      Services, Prepared Statement of................................    82
    Grady, Dr. Patricia A., Director, National Institute of Nursing
      Research, National Institutes of Health, Department of Health
      and Human Services, Prepared Statement of......................   120
    Gregg, Senator Judd, U.S. Senator From New Hampshire, Questions
      Submitted by...................................................   276
    Guttmacher, Dr. Alan E., Acting Director, National Human Genome
      Research Institute, National Institutes of Health, Department
      of Health and Human Services, Prepared Statement of............    91

    Harkin, Senator Tom, U.S. Senator From Iowa:
        Opening Statements of..................................63, 163, 237
        Questions Submitted by.................................31, 145, 206
    HIV:
        Law Project, Letter From the.................................   403
        Medicine Association, Prepared Statement of the..............   400
    Harlem United Community AIDS Center, Inc., Prepared Statement of
      the............................................................   417
    Health Professions and Nursing Education Coalition, Prepared
      Statement of the...............................................   408
    Home Safety Council, Prepared Statement of the...................   412
    Hodes, Dr. Richard J., Director, National Institute on Aging,
      National Institutes of Health, Department of Health and Human
      Services, Prepared Statement of................................    93
    HONOReform, Prepared Statement of................................   406
    Humane Society:
        Legislative Fund, Prepared Statement of the..................   413
        Of the United States, Prepared Statement of the..............   415
    Hutchison, Senator Kay Bailey, U.S. Senator From Texas, Question
      Submitted by...................................................   277

    Infectious Diseases Society of America, Prepared Statement of the   420
    Inouye, Senator Daniel K., U.S. Senator From Hawaii, Questions
      Submitted by.............................................54, 151, 259
    Insel, Dr. Thomas R., Director, National Institute of Mental
      Health, National Institutes of Health, Department of Health and
      Human Services, Prepared Statement of..........................   115
    International:
        Foundation for Functional Gastrointestinal Disorders,
          Prepared Statement of the..................................   423
        Myeloma Foundation, Prepared Statement of the................   425

    Jeffrey Modell Foundation, Prepared Statement of the.............   427

    Katz, Dr. Stephen I., Director, National Institute of Arthritis
      and Musculoskeletal and Skin Diseases, National Institutes of
      Health, Department of Health and Human Services, Prepared
      Statement of...................................................    97
    Kington, Raynard S., M.D., Ph.D., Acting Director, National
      Institutes of Health, Department of Health and Human Services..    63
        Prepared Statement of........................................    70
        Summary Statement of.........................................    65
    Kohl, Senator Herb, U.S. Senator From Wisconsin:
        Prepared Statement of........................................   187
        Question Submitted by........................................   154

    Landis, Dr. Story C., Director, National Institute of
      Neurological Disorders and Stroke, National Institutes of
      Health, Department of Health and Human Services, Prepared
      Statement of...................................................   118
    Landrieu, Senator Mary L., U.S. Senator From Loiusiana:
        Statement of.................................................   167
        Questions Submitted by.....................................154, 226
    Lindberg, Dr. Donald A.B., Director, National Library of
      Medicine, National Institutes of Health, Department of Health
      and Human Services, Prepared Statement of......................   123

    Maui Family Support Services, Letter From........................   436
    Mended Hearts, Incorporated, Prepared Statement of the...........   552
    MENTOR, Prepared Statement of....................................   432
    Mentor Consulting Group, Prepared Statement of the...............   429
    Montgomery County Stroke Association, Prepared Statement of the..   431
    Murray, Senator Patty, U.S. Senator From Washington:
        Prepared Statement of.......................................19, 166
        Questions Submitted by.................................55, 269, 223
        Statement of.................................................   164

    Nabel, Elizabeth G., M.D., National Heart, Lung, and Blood
      Institute, National Institutes of Health, Department of Health
      and Human Services.............................................    63
        Prepared Statement of........................................    77
    National:
        Alliance:
            For Eye and Vision Research, Prepared Statement of the...   443
            Of State and Territorial AIDS Directors, Prepared
              Statement of the.......................................   453
            To End Homelessness, Prepared Statement of the...........   440
        Association:
            For State Community Services Programs, Prepared Statement
              of
              the....................................................   448
            Of:
                Anorexia Nervosa and Associated Disorders, Prepared
                  Statement of the...................................   436
                County and City Health Officials, Prepared Statement
                  of the.............................................   438
                State:
                    Alcohol and Drug Abuse Directors, Prepared
                      Statement of the...............................   446
                    Directors of Career Technical Education
                      Consortium, Prepared Statement of the..........   451
        Coalition of STD Directors, Prepared Statement of the........   462
        Congress of American Indians, Prepared Statement of the......   456
        Consumer Law Center, Prepared Statement of the...............   459
        Down Syndrome Society, Prepared Statement of the.............   465
        Federation of Community Broadcasters, Prepared Statement of
          the........................................................   468
        Fragile X Foundation, Prepared Statement of the..............   470
        Health Care for the Homeless Council, Prepared Statement of
          the........................................................   472
        Marfan Foundation, Prepared Statement of the.................   473
        Network to End Domestic Violence, Prepared Statement of the..   475
        Primate Research Centers, Prepared Statement of the..........   484
        Psoriasis Foundation, Prepared Statement of the..............   479
        Public Radio, Prepared Statement of..........................   482
        Sleep Foundation, Prepared Statement of the..................   486
        Technical Institute for the Deaf, Prepared Statement of the..   488
        Union of Labor Investigators, Letters From the.............492, 493
        Wildlife Federation, Prepared Statement of the...............   494
    NephCure Foundation, Prepared Statement of the...................   466
    Niederhuber, John E., M.D., Director, National Cancer Institute,
      National Institutes of Health, Department of Health and Human
      Services.......................................................    63
        Prepared Statement of........................................    74
    Oncology Nursing Society, Prepared Statement of the..............   499
    Ovarian Cancer National Alliance, Prepared Statement of the......   497

    Pancreatic Cancer Action Network, Prepared Statement of the......   510
    Pettigrew, Dr. Roderic I., Director, National Institute of
      Biomedical Imaging and Bioengineering, National Institutes of
      Health, Department of Health and Human Services, Prepared
      Statement of...................................................    99
    Population Association of America/Association of Population
      Centers, Prepared Statement of the.............................   502
    Prevent Blindness America, Prepared Statement of.................   507
    Program for Appropriate Technology in Health, Prepared Statement
      of the.........................................................   505
    Pryor, Senator Mark, U.S. Senator From Arkansas:
        Prepared Statement of........................................    22
        Questions Submitted by.......................................   230
        Statement of.................................................   188
    Pulmonary Hypertension Association, Prepared Statement of the....   512

    Reed, Senator Jack, U.S. Senator From Rhode Island:
        Statement of.................................................   166
        Questions Submitted by.......................................   273
    Rodgers, Dr. Griffin P., Director, National Institute of Diabetes
      and Digestive and Kidney Diseases, National Institutes of
      Health, Department of Health and Human Services, Prepared
      Statement of...................................................   108
    Railroad Retirement Board, Prepared Statements of the..........517, 519
    Religious Coalition for Reproductive Choice, Prepared Statement
      of the.........................................................   515
    Ryan White Medical Providers Coalition, Prepared Statement of the   521

    Sebelius, Hon. Kathleen, Secretary, Office of the Secretary,
      Department of Health and Human Services........................   237
        Prepared Statement of........................................   240
    Shelby, Senator Richard C., U.S. Senator From Alabama:
        Prepared Statement of........................................   128
        Questions Submitted by.......................................   161
    Sieving, Dr. Paul A., Director, National Eye Institute, National
      Institutes of Health, Department of Health and Human Services,
      Prepared Statement of..........................................    88
    Solis, Hon. Hilda L., Secretary, Office of the Secretary,
      Department of Labor............................................     1
        Prepared Statement of........................................     6
        Summary Statement of.........................................     4
    Specter, Senator Arlen, U.S. Senator From Pennsylvania, Questions
      Submitted by...................................................   157
    Scleroderma Foundation, Prepared Statement of the................   527
    Society:
        For:
            Healthcare Epidemiology of America, Prepared Statement of
              the....................................................   530
            Maternal-Fetal Medicine, Prepared Statement of the.......   533
            Women's Health Research and the Women's Health Research
              Coalition, Prepared Statement of the...................   540
        Of Teachers of Family Medicine, Prepared Statement of the....   534
    Spina Bifida Association and Spina Bifida Foundation, Prepared
      Statement of the...............................................   524
    State and Territorial Injury Prevention Directors Association,
      Prepared Statement of the......................................   537

    Tabak, Dr. Lawrence A., Director, National Institute of Dental
      and Craniofacial Research, National Institutes of Health,
      Department of Health and Human Services, Prepared Statement of.   106
    TB Coalition, Prepared Statement of the..........................   546
    The:
        Friends of the National Institute on Aging, Letter From......   395
        Interstitial Cystitis Association, Letter From...............   420
    Tri-Council for Nursing, Prepared Statement of the...............   549
    Trust for America's Health, Prepared Statement of the............   543

    United Tribes Technical College, Prepared Statement of the.......   553

    Volkow, Dr. Nora D., Director, National Institute on Drug Abuse,
      National Institutes of Health, Department of Health and Human
      Services, Prepared Statement of................................   102

    Warren, Dr. Kenneth R., Director, National Institute on Alcohol
      Abuse and Alcoholism, National Institutes of Health, Department
      of Health and Human Services, Prepared Statement of............    95
    Whitescarver, Dr. Jack E., Director, Office of AIDS Research,
      National Institutes of Health, Department of Health and Human
      Services, Prepared Statement of................................   125

                                 SUBJECT INDEX

                                  ----------

                            DEPARTMENT OF EDUCATION

                            Office of the Secretary

                                                                       Page

    Access and Completion Incentive Fund.............................   196
    Additional:
        Committee Questions..........................................   206
        Support for States Related to Data Collection................   208
    Addressing:
        Immediate Fiscal Needs and Sustainable Reform................   186
        The Dropout Problem..........................................   188
    Administrative Cost of Originating all Federal Student Loans
      Through Direct Loan Program....................................   235
    Adult Literacy Programs and Reauthorization of the Workforce
      Investment Act.................................................   224
    American Recovery and Reinvestment Act...........................   163
        Funding for Postsecondary Education..........................   172
        Innovation Fund..............................................   229
    Basis for Awarding Loan Servicing Contracts......................   192
    Benefits of Dual Enrollment Programs.............................   185
    Budget Proposal to Make Pell Funds Mandatory.....................   172
    Career and Technical Education...................................   218
    Charter:
        School Program...............................................   234
        Schools......................................................   183
    Choice in Student Loans..........................................   235
    Community College Role--Academic and Job Skills..................   181
    Compliance and Technical Assistance Activities in the Office for
      Civil
      Rights.........................................................   222
    Data Collection:
        And The SDFSC Program........................................   225
        On LEA Reduction of Maintenance of Effort....................   206
    Data:
        On:
            LEA Reduction of Expenditures for Special Education Under
              the Individuals With Disabilities Education Act (IDEA).   206
            States Ineligible to Use Maintenance of Effort Reduction
              Authority..............................................   206
        Quality Campaign.............................................   201
    Delivery of Technical Assistance.................................   216
    Developing Comprehensive Data Systems............................   194
    Direct Loan Capacity.............................................   233
    Dropout Rate of Students with Disabilities.......................   178
    Dual Enrollment Programs and Dropouts............................   185
    Early Childhood Education.................................172, 174, 223
        And Special Education........................................   184
    Early Learning:
        Challenge Fund........................................172, 223, 227
        Programs.....................................................   178
    Economic Impact of High School Dropouts..........................   170
    Education Priorities.............................................   169
    Educational:
        Assurances for Education Reform..............................   168
        Materials in Accessible Formats..............................   210
    Estimated Savings From Shift to Direct Loans.....................   233
    Even Start.......................................................   226
    Expansion and Replication of Promising Charter School Models.....   229
    Federal:
        Facilities Funding for Charter Schools.......................   228
        Support for Early Learning Literacy Programs.................   224
    Findings From Monitoring Reviews of State VR Agencies............   216
    Fiscal Year 2010:
        Discretionary Funding Request................................   169
        Education Budget Priorities..................................   167
    Focus of Teacher Incentive Fund..................................   182
    Funding:
        For:
            Pell Grants..............................................   235
            Research on Adult Reading and Writing....................   220
        Sources for Program Improvement Strategies...................   208
        Support for Drug and Alcohol Abuse Prevention and Violence
          Prevention Programs........................................   226
    Gear Up Program..................................................   191
    Helping:
        More Kids go to College......................................   175
        Struggling Schools...........................................   195
    High School Dropouts.............................................   185
    Impact:
        Of Recovery Act Funds on Education...........................   168
        On Employment................................................   191
    Importance of:
        A Good Principal.............................................   200
        Arts and Physical Education Courses..........................   204
        Deficiencies Identified in State Monitoring Reviews..........   217
        Developing All Skill Sets in School..........................   205
        Mentoring....................................................   192
    Improving:
        Education for Students With Disabilities.....................   178
        Literacy Through School Libraries............................   198
        Teacher Quality..............................................   169
    Incentive Pay for Teachers.......................................   186
    Increased Federal Administrative Costs...........................   233
    Increasing:
        Instructional Time...........................................   169
        The High School Graduation Rate..............................   179
    Intergovernmental Job Training Programs Review...................   218
    Investing in:
        Innovation...................................................   196
        Talent.......................................................   194
    Literacy--Early Reading Programs.................................   224
    Loan Servicing Under Direct Loans................................   191
    Long-term Impact of Recovery Act IDEA Funds......................   207
    Longer School Year...............................................   193
    Major Findings of Research on Adult Reading and Writing..........   219
    Measuring the Effectiveness of the SDFSC State Grant Program and
      Mentoring Program..............................................   230
    Mentoring Resource Center........................................   231
    National:
        Institute for Literacy.......................................   218
        Research and Development Centers Research on Adult Literacy..   220
    New Incentives for Effective Teaching............................   174
    No Child Left Behind and Narrowing of Curriculum.................   204
    Obligation Period of Recovery Act Funds..........................   199
    Partnering School Programs With Business Needs...................   180
    Pell Grants and College Accessibility............................   176
    Perkins Loans....................................................   181
    Postsecondary Education........................................164, 165
    Presidential and Congressional Academies for History and Civics..   234
    Priorities in Use of Funds From American Recovery and
      Reinvestment Act (ARRA) and the Teacher Incentive Fund.........   227
    Program Administration Staff Increases...........................   221
    Programs Providing Transition to College Services................   191
    Promoting Innovation in Struggling Schools.......................   175
    Proper Use of Recovery Act Funds.................................   203
    Proposal:
        To Move FFEL to all Direct Loans.............................   190
        For all New Loans to be Direct Loans.........................   173
    Proposed:
        Budget:
            Increases................................................   165
            Savings and Program Eliminations.........................   173
        Move to all Direct Lending...................................   179
        Organizational Placement of Office of Civil Rights Staff
          Increases..................................................   223
    Race to the Top Fund.............................................   169
        And Charter Schools..........................................   199
        Competition..................................................   198
        Goals........................................................   194
        Request for Proposals........................................   195
    Raising College Graduation by 2020...............................   189
    Reading:
        Programs.....................................................   171
        Skills and Special Education.................................   185
    Recovery Act:
        Administrative Activities....................................   221
        Discretionary Education Funds................................   193
        Investment in Education......................................   204
    Recovery Funds for Title I and Special Education.................   171
    Recruiting and Retaining Special Education Teachers..............   209
    Rehabilitation Services and Disability Research--Vocational
      Rehabilitation State Grants Program............................   214
    Replacement of FFELP Loan Volume.................................   233
    Research on Adult Education and Literacy.........................   219
    Resources for Reviews of Centers for Independent Living..........   217
    Role of Local Student Loan Infrastructure........................   232
    Safe and Drug-free Schools:
        And Communities..............................................   230
            National Programs........................................   231
        State Grants.................................................   190
    Savings From:
        All Direct Lending...........................................   180
        Move to Direct Loans.........................................   190
    Scaling up What Works............................................   181
    School:
        Facilities...................................................   164
        Improvement Program..........................................   170
        Leadership Program...........................................   200
        Reform.......................................................   183
    Setting Higher Standards.........................................   194
    Special Education:
        Grants to States Program Improvement Strategies..............   208
        Technical Assistance and Dissemination Program...............   209
    State Longitudinal Data Systems..................................   201
    Statutory Funding Requirements Under SDFSC State Grants Program..   225
    Steps to Increase Direct Loan Capacity...........................   233
    Student Loan Volume..............................................   233
    Students and the Loan Process....................................   232
    Sustaining Recovery Fund Initiatives.............................   193
    Targeting:
        Recovery Resources--A Test of Leadership.....................   202
        Title I Funds to Lower the Dropout Rate......................   177
    Teacher Incentive Fund...............................170, 181, 227, 234
        Competitive Grants...........................................   183
    Technical Assistance for:
        Centers for Independent Living...............................   217
        LEAs for SDFSC Programs......................................   226
        Rural Institutions...........................................   232
        Special Education State Data Collection......................   207
    The Graduates Act................................................   189
    Title I Funding Gap..............................................   177
    Transition After Recovery Act Funds are Expended.................   202
    Turning Around Low-performing Schools............................   170
    Updated Guidance on Title I Waivers..............................   232
    Use of SFSF for Charter School Facilities Funding................   228
    Video Description:
        Grant Competition............................................   214
        Performance Assessment.......................................   214
    What Works:
        And Innovation Fund........................................169, 200
        Clearinghouse................................................   221

                    DEPARTMENT OF HEALTH AND HUMAN SERVICES

                         National Institutes of Health

    A:
        Structured Approach to Answering Key Questions...............    84
        Wide-ranging Effort..........................................    77
    Addiction Medications: Changing the Culture of Treatment.........   102
    Additional Committee Questions...................................   145
    Address Health Disparities.......................................   108
    Addressing the:
        Rising Burden of Noncommunicable Disease.....................    82
        Societal Implications of an Aging Population.................    95
    Advancing Implementation Science.................................    83
    Appreciation for Investment in Research Infrastructure...........    86
    Area of Promise and Investment:
        Managing Chronic Pain........................................    85
        Natural Products.............................................    85
        Translational Tools..........................................    85
    ARRA and Future Support..........................................   131
    Asthma Network...................................................    78
    Autism and Language..............................................   105
    Barker Hypothesis................................................   140
    Building a Matrix for Clinical and Translational Research........    86
    Cancer:
        And ARRA Funds...............................................   135
        Research Portfolio...........................................    90
    Cardiac Translational Research Implementation Program (C-TRIP)...    78
    Changing Healthcare Delivery Through Point-of-Care (POC)
      Technologies...................................................   100
    Clinical and:
        Population-based Research....................................   109
        Studies......................................................    99
        Transational Awards..........................................   161
        Trial of Hypertension Management Strategies..................    78
        Trials and Diagnostics.......................................    90
    Collaborations and Team Science..................................    98
    Comparative Effectiveness Research...............................   144
    Complex Genetic Diseases.........................................    98
    Curing Cancer....................................................   159
    Current Scope of the Problem and Research........................    95
    Cystic Fibrosis..................................................   128
    Dental Care in the Future........................................   108
    Developing Electronic Health Records.............................    77
    Discovery Research: Enabling Innovation..........................   127
    Doubling Cancer Research.........................................    74
    Early Detection, Diagnosis, and Treatment of Age-related Disease.    94
    Economic and Scientific Benefits of ARRA.........................    66
    Enhancing Future Health Research.................................   110
    Ensuring Access to Information in Times of Disaster..............   124
    Environmental:
        Disruptors of Endocrine Systems..............................   112
        Health and Safety of Nanomaterials...........................   112
    Esophageal Cancer................................................   148
    Ethical, Legal, and Social Implications..........................    92
    Expanding Research Capacity......................................    88
    Facing the Future................................................   106
    Finding and Funding Innovation...................................   114
    Fiscal Year 2010:
        Budget Request...............................................    66
        Priorities: Therapeutics Research............................   126
        Research Priorities: Prevention Research.....................   126
    Fostering T1 Translational Research..............................    87
    Genes and:
        Brain Diseases...............................................   119
        Environment: High Pay-off Research...........................   103
    Genetic:
        Factors in Complex Diseases..................................   109
        Studies Guide Treatments.....................................   113
    Genomic Function.................................................    92
    H1N1 Flu.........................................................   138
    Hair Cell Regeneration...........................................   104
    Health Information Technology....................................   100
    Hemoglobinopathies Data System...................................    78
    Hexavalent Chromium and Health...................................   112
    Identifying Genes Responsible for Communication Disorders........   105
    Improving:
        Research Informatics.........................................    88
        Technologies to Treat Hearing Loss and Balance Disorders.....   105
    Increasing Funding and Greater Number of Awards..................   154
    Information Services for the Public..............................   124
    Innovative Approaches and Novice Researchers.....................   152
    Insulin-producing Cells From Amniotic Fluid Stem Cells Treat
      Diabetes.......................................................   101
    Interstitial Cystitis............................................   150
    Investing Today for American Prosperity..........................   115
    Keep the Pipeline Strong.........................................   107
    Large-scale Sequencing...........................................    92
    Leveraging Partnerships to Benefit Biomedical Science............    87
    Liver and Bile Duct Cancer.......................................   148
    Lower Lp(a)......................................................   159
    Lung Cancer......................................................   149
    Maintaining U.S. Leadership in Global Health Research............    83
    Making Wise Decisions: Outreach..................................    86
    Maternal Fetal Medicine Research Network.........................   157
    Medical Sequencing...............................................    91
    Medicine of the Future...........................................    90
    Mental:
        Disorders are Chronic Brain Disorders........................   116
        Healthcare in the Future.....................................   116
    Microchip Captures Early Circulating Cancer Cells................   100
    Military Researchers.............................................   152
    Miniature Artificial Kidney Replaces Traditional Dialysis........   101
    Molecular Theranostics: New Technologies for the Diagnosis and
      Treatment of Diseases..........................................   101
    Moving:
        Forward......................................................92, 97
        Past a Legacy of Fear........................................    75
    Myeloma..........................................................   149
    NCCAM: Looking to the Future.....................................    86
    NCI and CIS......................................................   153
    NHLBI Proteomics Initiative......................................    79
    NIH:
        Budget With Presidential Initiatives.........................   158
        Medline Plus.................................................   150
    NINR:
        And the American Recovery and Reinvestment Act...............   122
        Research Programs............................................   121
    Neurological Disorders and the Environment.......................   111
    New Programs to Prevent and Treat Childhood Obesity..............    78
    Ophthalmic Genetics..............................................    88
    Outlook for the Future...........................................    96
    Ovarian Cancer...................................................   148
    Oversight of Objectivity.........................................   136
    Pancreatic Cancers...............................................   145
    Personalized Genomic Medicine....................................    91
    Pharmacy Program.................................................   151
    Physical Sciences Shine Light on Biology.........................   114
    Planning for the Future..........................................   118
    Prematurity and Respiratory Outcomes Program (PROP)..............    79
    Preventing Noise-induced Hearing Loss............................   104
    Prevention.......................................................   147
    Preventive Medicine..............................................    98
    Progress in Treatment and Prevention of Pancreatic Cancer........   146
    Promote Clinical Innovation......................................   107
    Promoting:
        Health Awareness.............................................   110
        Healthy Aging and Preventing Age-related Disease and
          Disability.................................................    94
    Public Health Burden of Mental Illness...........................   115
    Regenerating Brain Tissue to Promote Stroke Recovery.............   101
    Research:
        Priorities...................................................   135
        Training and Community Outreach..............................   127
    Resuscitation Outcomes Consortium (ROC) Renewal..................    79
    Salivary Diagnostics.............................................   157
    Sarcoidosis......................................................   160
    Scientific Information Resources.................................   123
    Self-management, Symptom Management, and Caregiving..............   121
    Small Business Innovation Research (SBIR) and Small Business
      Technology Transfer (STTR) Programs............................   154
    Stem:
        Cell Consortium..............................................    77
        Cells........................................................   158
    Stomach Cancer...................................................   149
    Stroke...........................................................   118
    Success Rate of ARRA.............................................   130
    Support of Promising Research and Flexibility....................   133
    The:
        AIDS Pandemic................................................   125
        Barker Hypothesis............................................   141
        Cancer Genome Atlas..........................................    91
        $1,000 Genome................................................    92
        1000 Genomes Project.........................................    92
        Power of the Genome..........................................    75
        Relevance and Impact of Comorbid Conditions..................   103
        Research Workforce...........................................   120
        Trans-NIH AIDS Research Program..............................   125
    Translating:
        Scientific Insights to Therapies.............................   119
        Technology Into Practice.....................................   100
    Translational Medicine...........................................    89
    Understanding:
        Healthy Aging and Disease and Disability.....................    93
        The Dynamics of Drug Abuse and HIV...........................   103
    Vaccines.........................................................   139
    Visual Neuroscience..............................................    90
    Vocal Fold Regeneration..........................................   106
    Wellness and Prevention..........................................   143
    Widen the Scope of Inquiry.......................................   107
    Windfall of Discoveries of the Genetic Basis of Disease..........    91

                            Office of the Secretary

    A Public Health Insurance Option.................................   253
    Additional Committee Questions...................................   259
    Administration:
        For Children and Families: Office of Head Start..............   262
        On Aging.....................................................   261
    Assisting Refugees to Achieve Self-sufficiency...................   272
    Centers for:
        Disease Control and Prevention...............................   262
        Medicare and Medicaid Services...............................   261
    Conquer Childhood Cancer Act.....................................   275
    Decision Makers Differ on How to Mend Broken Health System.......   244
    Emergency Housing Assistance.....................................   271
    Health Resources and Services Administration.....................   260
    Healthcare:
        Access in Rural America......................................   254
        Disparities..................................................   239
        Fraud and Abuse..............................................   258
        Reform.......................................................   238
        Waste and Hospital-acquired Infections.....................238, 244
        Workforce..................................................269, 275
    HHS:
        Grants Provided to Organizations Serving Native Hawaiians....   263
        National Diabetes Education Program..........................   261
    Home Visiting....................................................   269
    Immunizations....................................................   274
    Low Income Home Energy Assistance Program........................   273
        Funding Disparities..........................................   249
    Medical Countermeasures..........................................   277
    Native Hawaiian Healthcare.......................................   260
    NIDDK's Diabetes Education in Tribal Schools (DETS) Project......   261
    NIH:
        Funding......................................................   256
        Stimulus Funding.............................................   257
    Occupational Safety and Health Training Program..................   259
    Office:
        Of Minority Health...........................................   260
        On Women's Health (OWH)......................................   262
    Pandemic:
        Flu..........................................................   239
        Preparedness.................................................   274
    Practitioners....................................................   268
    Prevention and Wellness..........................................   247
    Quality of Healthcare............................................   250
    Refugee Resettlement Program.....................................   276
    Title X Family Planning Program..................................   270
    University of Pittsburgh Biodefense Initiative...................   256
    U.S. Domestic Refugee Program and the Economic Crisis............   270

                              DEPARTMENT OF LABOR

                            Office of the Secretary

    Additional Committee Questions...................................    31
    Administration of Work Opportunity Tax Credit....................    36
    Career Pathways Innovation Fund..................................    59
    Coalition of Immokalee Workers...................................    62
    COBRA Premium Assistance Program.................................    20
    Community Service Employment for Older Americans.................    58
    Contracting Authority Under WIA..................................    32
    Departmental Program Evaluations.................................    49
    Disability Navigators Initiative.................................    50
    Dislocated Worker Program........................................    16
    DOL Review of Ex-offender Programs...............................    33
    Employment:
        Of Persons with Disabilities.................................    14
        Statistics...................................................    21
    Ensuring Accountability and Transparency.........................    12
    Fair Labor Standards Act.........................................    22
    Farm Labor Conditions............................................    61
    Fiscal Year 2010 Priorities......................................     7
    Flex-options Project at the Women's Bureau.......................    47
    Funds for Job Corps..............................................    18
    Further Collaboration With the Department of Education...........    55
    Gulfport Jobs Corps Center.......................................    15
    High-Growth Job Training Initiatives.............................    56
    Hiring at OSHA...................................................    38
    ILAB:
        Funding......................................................48, 49
        Project Portfolio............................................    48
    Improving the Employment Process for Individuals With
      Disabilities...................................................    51
    Innovative Workforce Training Strategies.........................     9
    Job Corps Operations.............................................    52
    Monitoring One-stop Access by Individuals With Disabilities......    33
    National Emphasis Program on Recordkeeping.......................    37
    Noncompetitive Grants............................................    60
    Office of the Solicitor..........................................    40
    Other Programs...................................................    12
    Pell Grants for Unemployed Workers...............................    17
    Performance Targets for ODEP.....................................    49
    Program Direction and Support....................................    39
    Re-employment Eligibility Assessments............................    35
    Responding to Worker Displacement in American Samoa..............    54
    Restoring Worker Protection Programs.............................     7
    Senate Confirmations.............................................    24
    Severe Violators Enforcement Program.............................    39
    Slot Reallocations at Job Corps Centers..........................    53
    Survey of Occupational Injuries and Illnesses....................    39
    Transitional Jobs Programs.......................................    33
    Transitioning Veterans Into Civilian Employment..................    57
    Unemployment Overpayments........................................    21
    Veterans' Employment and Training Service........................    21
    WIA:
        Dislocated Worker Formula....................................31, 60
        Youth Activities.............................................    56
    Wage and Hour Division...........................................    36
    Work Incentive Grant Program.....................................    59
    Workforce Data Quality Initiative................................    32

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